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proud -> Comments on this please (December 14, 2007 10:39:42 AM)

German acupuncture trials(GERAC) for chronic low back pain

[url]http://archinte.ama-assn.org/cgi/content/abstract/167/17/1892[/url]

I see that the Canadian Physiotherapy Association(CPA) has a media release that supports this study. I only see the abstract, but from that....I really question why this study is being supported. It appears sham was also effective. What is that telling us?

Has anyone read the full text? Anyone care to comment on the abstract and why the CPA seems so excited about this study?




Bournephysio -> RE: Comments on this please (December 14, 2007 12:52:06 PM)

Would you be more in favour of the study if it was described as acupuncture technique 1 versus acupuncture technique 2 versus conventional therapy? Sham is just a word they used to represent the treatment group. It doesn't mean that the treatment was a sham.

Wouldn't you be excited by a study that shows what we do works? Sounds like a decent study from the abstract. I don't understand why you "really question why this study is being supported."

Doug



SJBird55 -> RE: Comments on this please (December 14, 2007 1:24:26 PM)

I'd think a full text would be helpful. 

In the abstract, the results do not mention the number of patients that were non-responders for each category - this would be an important factor.  I'd also be curious at to what guidelines were followed.  There is research indicating the importance of improving effectiveness by appropriately classifying patients.  Chronic back pain isn't necessarily a treatment based classification system by itself.  It is a description of time that back pain has been occurring and nothing more.  Generally speaking, "guidelines" are way too broad to be terribly helpful to a clinician.  I'm not sure what "guideline based conventional therapy" is nor who was to be following those quidelines.  Comparing one particular intervention to something that is quite broad in nature can lead to erroneous conclusions because the broader the category the greater chance of a washout effect. 



Shill -> RE: Comments on this please (December 14, 2007 1:45:43 PM)

I am not sure how one can actually "sham" accupuncture.  Needles going into the skin are needles going into the skin.  How can one fake that?  I also object to the words "Conventional Therapy".  For low back pain, there is really no such thing, unfortunately.  Perhaps the Germans do things consistently across the board for the LBP population, but we have all seen the myriad of treatments, good and bad, with LBP management in PT in this country.  (USA, cant speak for Canadians). 
They do reference the German guidelines for conventional therapy in the literature at the end of the study, but I see that these are in German.  From the text:
Patients in the conventional therapy group received a multimodal treatment program according to German guidelines.
(11. AKDA¨ . Empfehlungen zur Therapie von Kreuzschmerzen. 2 ed. Du¨sseldorf, Germany:
Nexus GmbH; 2000.)
The guidelines provide the treating physician with recommendations about the treatment algorithm and assess the various
therapy forms according to the degree of evidence based on a literature search and recommendations of the specialist associations.
Conventional therapy included 10 sessions with personal contact with a physician or physiotherapist who administered
physiotherapy, exercise, and such.
Furthermore, expanding on the sham versus real accupuncture, they do go on to say this:
The comparison of sham vs verum acupuncture was intended to differentiate the physiologic (specific) from the
psychologic (nonspecific) effects of acupuncture. Among the nonspecific effects for both forms of acupuncture are positive patient expectations about acupuncture paired with negative expectations about conventional medicine, more intensive physician contact, and the experience of an invasive technique (needling). Given that the 2 forms of acupuncture are indistinguishable to the patient,any differences in outcomes between the 2 forms must be attributable to specific treatment effects. However, the 2 forms did not differ insofar as the primary outcome.This cannot be explained solely by positing the existence of additional, previously unknown acupuncture points or regions because in the sham acupuncture, needles were inserted only very shallowly and
without elicitation of de Qi. Several other hypotheses must be considered instead: (1) there are no specific acupuncture effects at all; (2) the specific acupuncture effect is very small and is overlaid by nonspecific effects; and (3) there exist specific acupuncture effects, the nature of which is still unknown,that lead to symptom improvement independent of point selection and depth of needling.



proud -> RE: Comments on this please (December 14, 2007 2:03:27 PM)

ah Doug...you and me and acupuncture yet again. Note that I stated that I had only read the abstract so I have little in which to make a judgement. I think Sj and Shill had the correct questions however.

In the abstract they say this:


quote:

"....consisting of superficial needling at nonacupuncture points...."



So Doug, being a proponent of acupuncture I gather....can you help explain how this study supports "acupuncture". If I can poke someone anywhere...randomly.....I fail to see how that forms a critically applied treatment that 'supports" what we do. I mean....John Henry Clampett down the street can do that....

I know you to be an intelligent poster Doug so my question is intended to gather your perspective and not dismiss acupuncture. Upfront however, I am not a fan of the poking with needles.



jlharris -> RE: Comments on this please (December 14, 2007 11:25:11 PM)

I posted on this when it first came out.  Go here for the post.  My last post also includes a link to the full text.  Hopefully still good.  It has also been very well blogged on by Ben Goldacre over at Bad Science (clink on the blog name for the post) and Orac over at Respectful Insolence.  And these are just two blogs I read.  I'm sure one can find others commenting on this.  Here is my take, and one that is shared by others:

1.  Population was already one that "traditional medicine" had already failed.  Therefore, to think it would do better than a novel treatment is almost absurd.  And over a 1/4 of these pt's still improved with what had failed them in the past.

2.  "Sham" and "Real" acupuncture did basically the same - in terms of improvement.  What does this say?  Either there are no merridians and just poking with an needle anywhere produces a physical response - or... all acupuncture is "sham".  Meaning, because these people had already failed with "traditional" medicine, a novel treatment presented as a legitamate treatment for pain produced a strong placebo effect seen in both groups believing they were recieving "real" acupuncture - while on was not.

3.  And, IIRC, participants in the acupunture group(s) were allowed to additionally have treatments from the "traditonal" medicine threrapies.

In the end, my opinion is that this study did not show that acupuncture works, but that for those with 8+ year history of LBP in which traditional treatments did not work for, doing more traditional treatments will help 1/4 of you compared to a placebo.



Bournephysio -> RE: Comments on this please (December 15, 2007 11:02:49 AM)

Despite not subgrouping patients, acupuncture was more effective.

Despite not formally including exercise, acupuncture was effective.

“Sham” vs “real” acupuncture had similar results which is consistent with the literature. John Henry Clampett can manipulate as well. Weren’t you arguing the opposite side of the “skilled”, “unskilled” argument when it came to manual therapy? If it works, I don’t care how much skill is required to apply it.

You can’t tell from the abstract what treatment these people had before but usually people in chronic pain have failed conventional treatment. That’s the nature of chronic pain. So what?

There is no reason to conclude that acupuncture is placebo anymore than manual therapy.

We need to be as unbiased as possible when reading a study. It is apparent that some reading this study have decided that acupuncture doesn’t work beforehand (“Upfront however, I am not a fan of the poking with needles.”) and are analyzing the study based on this. Ask your yourself whether you would come to the same conclusion if this same study was about your favourite treatment. I’ve seen this kind of bias too frequently here and not just for acupuncture.

No this study doesn’t prove that acupuncture works but it does support it. I don’t see how you can objectively say otherwise. This is not the only study that supports acupuncture. The studies that I have seen are more consistently positive than almost any treatment modality that we use and this is before subgrouping and including exercise both of with were key components to showing that manual therapy works.



proud -> RE: Comments on this please (December 15, 2007 11:34:03 AM)

Well actually Doug, I agree with everything you said. Especially regarding the special skill of manipulation.

The special skill in my view is understanding "better'....the aspect of selecting a specific treatment for a specific sub group. Acupuncture may fit in there somewhere. But my guess is that it is not the "acupuncture"( as the public views it) that is driving the effect so we have to be careful with how this is explianed to patients. Same goes for how we explain the effects of manipulation.

No....I do not like acupuncture as a singular treatment for chronic pain. Plenty of studies that demonstrate the deeper aspects of chronic pain. These patients require education on pain physiology, hurt versus harm, CBT specialists and yes in many cases...exercise. I could probably support randomly poking with needles as an adjunct to a focused treatment approach, but that is not what this study does. So I don't like the study.

I just fail to see why the CPA is placing this in their "media" release section when other favourable studies exist to support what we traditionally are known for.

Again, this study is yet another generalized study showing favourable results for chronic pain type pain by poking randomly with needles. My requesting comments was intended to be just that....to request comments.

Is it biased to align what Jharris said about this study? Or is it thinking critically? I think the latter which is why I am concerned with our professional association picking this study among many to champion. It's an odd choice Doug.....in my humble opinion.



jlharris -> RE: Comments on this please (December 15, 2007 12:00:08 PM)

Did you call me "John Henry Clampett"?  That usually works.  My argument sucks because I'm some backwoods idiot.  BTW, I read the FULL TEXT.  So I know what the treatments were and were not.  Go ahead and read the full text yourself and then let me know what you think of my opinions, specifically - not what kind of person I am - and we'll go from there.

Acupuncture benefited those with chronic LBP greater than 8 years, in which "traditional" medicine had not helped.  Plain and simple.  So, if I get a pt in my clinic with LBP that has been going on for 8 years or greater, I may consider sending them to an acupuncturist, Homeopath, therapeutic touch, or whatever practisioner that relies on placebo and rituals to get people better. 



proud -> RE: Comments on this please (December 15, 2007 12:54:03 PM)

Ha, Jason. I laughed at your last post.

But It was "I" that drummed up "John Henry Clampett" in reference to how non skilled it is to perform sham acupuncture. Doug then pointed aout that the same argument could be applied to manipulation....which is of course accurate but not relevant to the problems with the Canadian Physiotherapy Association(CPA) championing the study( in my opinion).

Anyway. I laughed.



Bournephysio -> RE: Comments on this please (December 15, 2007 1:04:25 PM)

Proud, Jason in his first post makes 3 points that at least need to be considered but then makes conclusions that are obviously biased and unsupported. To align yourself with those conclusions is biased.

I don’t follow cpa press releases so I can’t comment on what they choose to make press releases about but it may be to educate the public that we do acupuncture as much as it is to show that it is effective. Out west needling of some type is very common. I think only one therapist in our clinic doesn’t needle in one form or another. Everyone in my wife’s clinic needles. Both are fairly large clinics.

Jason, thank you for clearly showing that you can’t think or read objectively. I suggest you reread this thread, then reread the article and let us know exactly what the treatments were and were not. Much more productive than calling yourself “some backwoods idiot.”

“Acupuncture benefited those with chronic LBP greater than 8 years, in which "traditional" medicine had not helped. Plain and simple.” Assuming your correct that they all received traditional medicine this is a pretty good summary.

“I may consider sending them to an acupuncturist, Homeopath, therapeutic touch, or whatever practisioner that relies on placebo and rituals to get people better”
This is where your argument completely falls apart. You have no evidence that acupuncture relies on placebo nor any evidence that homeopath, or therapeutic touch works as well as acupuncture or that what you do relies any less on placebo.



proud -> RE: Comments on this please (December 15, 2007 1:34:34 PM)

Doug,

Insinuating that I am biased does not make it so.

How about commenting on what is known about chronic pain. The central changes that occur. The work of Lorimer Moseley and Butler. The psycho-social aspects of chronic pain etc etc.

Randomly poking with needles appears to have a neuro-modulatory effect. There are many ways to accomplish that.  So I would like to ask how that can be effectively incorporated into a treatment plan that appropriately takes into account the complexity of chronic pain

Comment on the fact that this study does nothing really other than once again suggest that we can modulate pain.....for a period of time. Again, amongst better work on chronic pain out there, I do not support the CPA's choice to select this one to champion.

If what you are suggesting Doug is that this study said acupuncture worked so that should be enough....and those that raise an eyebrow are biased; I don't agree with that either.

"Upfront" I am skeptical about acupuncture because I have yet to see acupuncture in a study that I think has been designed very well....this one for example....."conventional therapy"? Shill made the comments above to speak to that.  I would like to see acupuncture for chronic pain compared against some treatments that actually do have support( education on pain physiology, graded exposure, CBT etc). From there perhaps the neuro-modulatory effects of randomly poking with needles could be incorporated. But then again....I doubt I need acupuncture to accomplish that( in my anecdotal opinion).



Bournephysio -> RE: Comments on this please (December 15, 2007 2:23:25 PM)

“Insinuating that I am biased does not make it so.”
No, but if you agree with Jason’s conclusions you clearly all. You just can’t logically make those conclusions. We can both think critically, with relatively little bias and come to different beliefs but some things are obviously not logical. You may believe that acupuncture is placebo (you would have to also believe that not all placebos are created equal) but there really isn’t any evidence to support this so you can’t conclude this. Lumping acupuncture in with homeopathy is also illogical because of the completely different levels of evidence.

“How about commenting on what is known about chronic pain. The central changes that occur. The work of Lorimer Moseley and Butler. The psycho-social aspects of chronic pain etc etc.

Randomly poking with needles appears to have a neuro-modulatory effect. So I would like to ask how that can be effectively incorporated into a treatment plan that appropriately takes into account the complexity of chronic pain.

Comment on the fact that this study does nothing really other than once again suggest that we can modulate pain.....for a period of time. Again, amongst better work on chronic pain out there, I do not support the CPA's choice to selct this one to champion.
”

Just like manual therapy, acupuncture appears to be neuromodulatory. It is fairly likely that pain education, CBT and exercise are as well but they don’t require continuous visits to a physio. I suspect that the results would have been much more impressive if acupuncture was added to a comprehensive chronic pain program. I would never just do acupuncture to anyone in chronic pain (or just about anyone for that matter). 6 months is a decent follow up but I suspect that the differences would be less at one year. That is one of the things that is impressive about this study; they got good results with just acupuncture.


“If what you are suggesting Doug is that this study said acupuncture worked so that should be enough....and those that raise an eyebrow are biased; I don't agree with that either. "upfront" I am skeptical about acupuncture because I have yet to see acupuncture in a study that I think has been designed very well.”

I am suggesting that this is one study that shows an effect for acupuncture that is consistent with the literature. On its own it doesn’t prove anything. When taken in context with the rest of the literature, it is highly suggestive. Raising an eyebrow isn’t necessarily biased but making erroneous conclusions is.

Comparing acupuncture to conventional therapy gives it some clinical validity (at least in Germany). I have absolutely no desire to see acupuncture put up against CBT or any other treatment. I would much rather see CBT with and without acupuncture (by the way event the CBT literature seems up and down).

“I doubt I need acupuncture to accomplish that” I’ve seen this argument many times with manipulation. No I doubt you need it but if it really is effective why wouldn’t you use it. Anecdotally, I find it to be the most consistent modality that I use for obtaining large immediate decreases in pain. Also anecdotally, specificity is often very important but very unpredictable. random needling will give you an effect but the amount of the effect is often dependant on the exact placement of the needles and the exact form of stimulation (ims, versus traditional versus electro).



OAK -> RE: Comments on this please (December 15, 2007 2:47:07 PM)

This study is full of holes.

How can one compare "Physical Therapy" treatment to accupucture when Physical Therapists do accupuncture?  It's a contradiction.  It's reminiscent of the studies that compare spinal manipulation treatment to Physical Therapy treatment.

Also, chronic pain patients should be managed actively not passively.




jlharris -> RE: Comments on this please (December 15, 2007 3:21:46 PM)

Doug,

No doubt your ad hominem attack made my second post very extreme.  It still obvious you made no rebuttals to my points but that I have no idea what I'm talking about. 

What traditional therapy included:
quote:

The therapies given in the conventional
group were physiotherapy (n=197; mean, 11.7 sessions
per patient), massage (n=180; mean, 9.5 sessions
per patient), heat therapy (n=157; mean, 9.7 sessions per
patient), electrotherapy (n=65; mean, 8.8 sessions per
patient), back school (ie, a practical education in the management
of back pain) (n=36; mean, 8.1 sessions per patient),
injections (n=48; mean, 5.6 per patient), and guidance
(n=56; mean, 4.2 sessions per patient). In a few
patients, therapies included infusions, yoga, hydrojet treatment,
and swimming. Pharmacologic treatment in the
conventional therapy group consisted of analgesics in 95%
of patients (n=183; mean, 16.2 per patient).

hmmm...that seems easily reproducible for a validation study. (sarcasm)

Inclusion criteria:
quote:

Inclusion criteria were as follows: age 18 years or older, clinical diagnosis of chronic low back pain for 6 monthsno previous acupuncture for treatment of chronic low back pain or longer, mean Von Korff Chronic Pain Grade score7 of grade 1 or higher and a Hanover Functional Ability Questionnaire score of less than 70%, 8 , and
signed informed consent.


So, they've been to a healthcare provider at some point to be clinically diagnosed with chronic LBP, and have not had acupuncture in the past.  My opinion, then, is that since they've been - at least once - to a healthcare provider it is likely they've had one of the 10 treatments or who knows how many pharmacologic treatments in their past (again, AVERAGE of 8 years of LBP).  But NOT acupuncture.  Hmmm, I would argue, this eliminates those who have failed with acupuncture but expect those who have failed with traditional therapy to some how forget about that when assigned to that group for this study. 

Also, to quote myself:
quote:


2.  "Sham" and "Real" acupuncture did basically the same - in terms of improvement.  What does this say?  Either there are no merridians and just poking with an needle anywhere produces a physical response - or... all acupuncture is "sham".  Meaning, because these people had already failed with "traditional" medicine, a novel treatment presented as a legitamate treatment for pain produced a strong placebo effect seen in both groups believing they were recieving "real" acupuncture - while on was not.

So as you can see, I do give TWO options of what the meaning of the sham and real having same outcome.  It ends up that MY OPINION is that it is the latter.  You are free to disagree; and, from this study, would have just as much weight.

I have read, and reread this article.  Spoken with others about it.  Discussed their opinions vs mine.  Been swayed away from my initial views at times.  An argument that I have not read it, therefore my viewpoint is worthless does not hold up.

quote:

Jason, thank you for clearly showing that you can’t think or read objectively. I suggest you reread this thread, then reread the article and let us know exactly what the treatments were and were not. Much more productive than calling yourself “some backwoods idiot.”

Awesome.  Again, like most posts of yours Doug, looking for specific arguments and not just attacks on the poster.



Bournephysio -> RE: Comments on this please (December 15, 2007 5:25:18 PM)

What ad hominem attack? I don’t see what I posted that made you go on your tirade.

My reply which may be harsh (I apologize) but it is supported by what you said. You thought I called you “John Henry Clampett” so you obviously didn’t read the thread closely and you said “traditional treatments did not work for, doing more traditional treatments will help 1/4 of you compared to a placebo.” so you obviously didn’t read the paper very well.

Using traditional therapy gives the study external validity. You are comparing acupuncture to the treatment patients would have otherwise received.

You have not supported your opinion that acupuncture is placebo or why the placebo would last until a 6 month followup whereas there is literature supporting non-specific effects of needling. This also seems to be a common theme (i.e. non-specific effects of manipulation)

“An argument that I have not read it, therefore my viewpoint is worthless does not hold up.”
I have never argued this.

“Awesome. Again, like most posts of yours Doug, looking for specific arguments and not just attacks on the poster.”
So who is attacking the poster? I’m not the one who went into a tirade. I agreed with your summary: “Acupuncture benefited those with chronic LBP greater than 8 years, in which "traditional" medicine had not helped. Plain and simple.” so I don’t know what your problem is.

Here are some references that I posted in one of the previous threads:
1. Brinkhaus B, Witt CM, Jena S, Linde K, Streng A, Wagenpfeil S, Irnich D, Walther HU, Melchart D, Willich SN: Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 166:450-7, 2006
2. Ernst E: Acupuncture--a critical analysis. J Intern Med 259:125-37, 2006
3. Huang MI, Nir Y, Chen B, Schnyer R, Manber R: A randomized controlled pilot study of acupuncture for postmenopausal hot flashes: effect on nocturnal hot flashes and sleep quality. Fertil Steril 86:700-10, 2006
4. Itoh K, Katsumi Y, Hirota S, Kitakoji H: Effects of trigger point acupuncture on chronic low back pain in elderly patients--a sham-controlled randomised trial. Acupunct Med 24:5-12, 2006
5. Joos S, Wildau N, Kohnen R, Szecsenyi J, Schuppan D, Willich SN, Hahn EG, Brinkhaus B: Acupuncture and moxibustion in the treatment of ulcerative colitis: A randomized controlled study. Scand J Gastroenterol 41:1056-63, 2006
6. Kaptchuk TJ, Stason WB, Davis RB, Legedza AR, Schnyer RN, Kerr CE, Stone DA, Nam BH, Kirsch I, Goldman RH: Sham device v inert pill: randomised controlled trial of two placebo treatments. BMJ 332:391-7, 2006
7. Martin DP, Sletten CD, Williams BA, Berger IH: Improvement in fibromyalgia symptoms with acupuncture: results of a randomized controlled trial. Mayo Clin Proc 81:749-57, 2006
8. Trinh KV, Graham N, Gross AR, Goldsmith CH, Wang E, Cameron ID, Kay T: Acupuncture for neck disorders. Cochrane Database Syst Rev 3:CD004870, 2006
9. Willich SN, Reinhold T, Selim D, Jena S, Brinkhaus B, Witt CM: Cost-effectiveness of acupuncture treatment in patients with chronic neck pain. Pain 2006
10. Witt CM, Jena S, Selim D, Brinkhaus B, Reinhold T, Wruck K, Liecker B, Linde K, Wegscheider K, Willich SN: Pragmatic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 164:487-96, 2006
11. Wong RH, Lee TW, Sihoe AD, Wan IY, Ng CS, Chan SK, Wong WW, Liang YM, Yim AP: Analgesic effect of electroacupuncture in postthoracotomy pain: a prospective randomized trial. Ann Thorac Surg 81:2031-6, 2006



proud -> RE: Comments on this please (December 16, 2007 11:01:13 AM)

well Doug,if you are suggesting myself and jason and everyone else who commented are biased, then I propose that you are biased in the opposite direction; towards random pokings.

I think it is an innaccurate characterization of Jason for you to say that he has displayed an inability to think or read objectively. Clearly from all previous posts...including those within this thread that is inappropriate.

Most PT's in my area poke people. I am certified to poke people. However I have thought and read a great deal on the topic and it just does not sit well with me to sugest random pokings as a form of treatment for those in persistent pain is a good idea. As I stated before, one could make the argument to incorporate as part of a program, however, even if utilized as a multi-factorial adjunct to treatment I think what the patient "thinks" plays a key role in the pain modulation. And from that, when it comes to chronic pain, I worry about those that choose that form of treatment. Random pokings tends to take the onus of responsibility away from the patient in persistent pain... just as a starting point of critisicm. When selecting a treatment one should be asking....what is consistent with the literature on chronic pain? Not..."oh well this person has pain so let's do yet another thing to settle the symptoms for a period of time" 

You made the argument that manipulation has it's problems as well in terms of application. True, but if applied as the literature suggests....in acute stages, there is a difference. Chronic pain is more complex isn't it?

There is much published literature on "chronic pain" and I just have a problem with almost all literature regarding acupuncture for chronic pain....including that list you threw out there. YES...we can modulate pain. Alright, but as experts, there is more to it. Ther NEEDS to be more to it, otherwise we may as well just accept that all kinds of alternative medicine seems to modulate pain. So what?

Specifically this German study IS full of holes( pardon the pun). And the point:  Why does the CPA choose this one to have a media release on? There is much literature out there that supports the more traditional aspects of PT so why do we choose to align ourselves with alternative medicine? I just don't get that. Unless the thinking is.....oh well, it does something so let's supports it.



SJBird55 -> RE: Comments on this please (December 16, 2007 2:39:31 PM)

If someone has a link to the full text or can email an abstract (edit... I meant PDF, oops), that would be helpful. 

I can't infer if patients had 10 or 15 visits consisting of 30 minutes.  I also am not familiar with the pain scale used.  I have no idea what the Hanover Functional Ability Questionnaire is or how it is scored.  I would be willing to bet that a 12% change was probably the MCID or the MCD for that tool.  Now the abstract doesn't actually state the beginning levels of function nor the ending levels of function and only defines that for a positive outcome the patient was required to have a 33% change in pain OR a 12% change in function.  So, additionally from the abstract, I can't tell if pain predominantly changed or if function predominantly changed. 

I do know though that in my opinion, that based on my experience, patients in chronic low back pain typically (as a guesstimate) have a range of 32-50% disability on the Spinal Functional Index.  (This tool hasn't been published yet but it seems a bit better in capturing disability than the Revised Oswestry in my opinion because I don't have patients asking me to interpret the statements they are evaluating).    So... if the services I provide impact function via a change in function by 12%, that means that the patient is discharged with a disability of 20-38%.  My written goals are generally to have a discharge of 10-12%, which would mean to me that if the bare minimum of a clinically relevant change occurs, that minimum amount of change still isn't good enough probably from a patient perspective (and it definitely isn't good enough to me).

Since Jason provided some "conventional therapy" information... I don't know if "physiotherapy" was just "physiotherapy" or if what Jason posted describes what interventions were provided in "physiotherapy."  (When I add up the n values, I'm going to assume some of those interventions were what were provided during physiotherapy.)  I do know though that based on current literature for patients in chronic pain that:  1)  massage is ineffective (and 180 patients received that) 2)  heat therapy is ineffective (and 157 patients received that) 3) electrotherapy - if it was TENS is ineffective (and 65 patients received that) 4)  back school hasn't proven to be effective (and 36 patients received that) and 5) guidance has been shown to be effective for those in acute pain, but not necessarily for chronic pain.  It truly appears to me that the "conventional therapy" may have been hugely skewed with known ineffective interventions.  For those in chronic pain, education on pain, cognitive behavioral therapy is showing some benefit, specific exercises are showing some benefit and general exercise is showing some benefit.  In my opinion, it doesn't appear that "evidence" for this particular patient population was actually applied for patients in the "conventional therapy" category. 

My conclusion just from the abstract and the bits and pieces you all have shared is that something happened with acupuncture and it didn't matter where needles went into the skin.  We don't know what patients were told about that particular intervention and we don't know the beliefs of the patients nor the expectations of the patients.  (There is research that supports the the more the intervention matches perceptions the better the outcome.)  Both real and sham acupuncture outperformed ineffective conventional therapy.  I'd assume that conventional therapy that has been shown to be ineffective would still be shown as ineffective.  So, the results of a small percentage of effectiveness of this "conventional therapy" definitely isn't surprising to me. 

Since the abstract didn't share the the specifics of the amount of change... to me, without knowing the specifics, just a 12% functional change in that particular population would still have substantial deficits and 12% was chosen probably as the statistically relevant number, but still doesn't inherently mean that a patient would be satisfied with the final results.  When looking at outcomes, in my opinion, it is just more than realizing that the bare minimum of change occurred - outcomes should also potentially include if the results were satisfying results for the patient.  If a patient is required to perform an occupation in an office setting and still can't sit for more than 30-45 minutes at a time, the patient probably isn't going to be satisfied with the minimum amount of change.

Two questions occur from reading the abstract and your discussion:  1)  What would have happened if the small bit of evidence we do have for these types of patients was truly applied and put head to head with acupuncture?  2)  What did the patients that received acupuncture both real and sham look like qualitatively?



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