The Effectiveness of Acupuncture on Chronic Neck Pain - Essay Example

Chapter 3: Literature Review 3 Results Using the methodology presented in chapter 2 nine randomised controlled trials (RCTs), were selected and reviewed. These randomised controlled trials were then assessed using the STRICTA guidelines in order to estimate their relevance to the study. This was performed in order to assess the adequacy of the articles in terms of evidence of the effectiveness of acupuncture in back pain. 3.2: Treatment effectiveness 3.2.1: Acupuncture versus placebo White et al 2004: Acupuncture versus placebo for the treatment of chronic mechanical neck pain: a randomised control trial – Annals of Internal Medicine 2004 In the study by White et al (2004) it was found that acupuncture reduced neck pain and produced a statistically significant effect in study participants when compared with placebo. This effect however was not found to be clinically significant. The design of the study was a randomised, single-blind, placebo controlled, parallel-arm trial. The sample of participants was selected from two outpatient departments in the UK, with a total of 124 study participants in total completing the trial. The participants selected were between 18 and 80 years old, and were all selected on the criteria of having chronic, mechanical neck pain. The study was measured on an outcome basis, with the primary outcome being continued pain after one week of treatment. Secondary outcomes were pain at other time points, score on the neck disability index and the Short Form-36, and use of analgesic medications. Patients received either 8 treatments with acupuncture over the space of 4 weeks or 8 treatments of mock transcutaneous electrical stimulation of acupuncture points. While the acupuncture was found to be effective in relieving the neck pain, it was found not to be clinically significant as the placebo group were also found to improve from the baseline. Based on the primary outcome of pain one week after beginning treatment, the study found only a 12% better improvement in those receiving acupuncture than those receiving the placebo. This small percentage was not deemed to be clinically significant despite being classed as statistically so. There were recognised to be limitations in the study, however. Although the treatments were all carried out by one practitioner, the control did not mimic the process of needling, which may have affected the credibility of the placebo. There was also no control by means of a non-intervention group, which could have been used to measure the significance of the treatment in comparison to patients having received no treatment at all for the neck pain. The study did not make any assessment to the safety of the procedure. Overall from this study, it would be concluded that acupuncture is not effective enough in treatment of neck pain to warrant the treatment being used in practice. Vas et al 2006: Efficacy and safety of acupuncture for chronic uncomplicated neck pain: a randomised controlled study – Pain 2006 Dec 15;126(1-3):245-255 The findings from the study by Vas et al (2006) contrasted those of White et al (2004). The study by Vas et al found that acupuncture was more effective than the placebo in controlling neck pain. The design of this study was also a randomised, single-blind, placebo controlled study. The sample participants were selected from a Primary Care Centre in Spain and a total of 123 completed the study, which meant that the numbers were similar to those in the White et al study. The patients selected were all aged over 17 years, although mention is made of the maximum age in the group. They were selected on the basis of having uncomplicated neck pain of over three months duration, which means that the participants were also similar to those in the White et al study. The primary outcome measures in this study were more precise than those in the White study and were based on changes in intensity of pain rather than simply presence of pain. The secondary outcome measure was the discapacity of the participant, measured on the Spanish neck pain questionnaire. As in the White et al study, patients were randomly assigned to receive either acupuncture treatments or mock electrical stimulation of acupuncture points. The treatments in this study were composed of five sessions over three weeks. The study found that overall there was a change in only 20% of the mean neck pain intensity in the control group, while there was a change of over 60% in the group receiving acupuncture. The study also found that the results remained similar six months after treatment. The results of this study overall suggest that acupuncture is effective in comparison to the placebo in treating neck pain. The difference between this and the White study is likely due to the more specific approach used in measuring the primary objective. Zhu and Polus 2002: A controlled trial on acupuncture for chronic neck pain – The American Journal of Chinese Medicine 2002;30(1):13-28 In the study by Zhu and Polus (2002) it was found that the use of Chinese acupuncture had no significant effect in the treatment of neck pain. The design of this study was also a randomised, single blind, controlled study. There is no mention in the study where the sample participants were recruited from, however they were all selected on the basis of having chronic neck pain, which in this case included those with degenerative joint disease and soft tissue injuries. The participants in this case were all aged between 31 and 70, which makes them a slightly older age group than the previous two studies examined. In this study, only 29 volunteers completed the trial, and these were randomly selected to receive either Chinese medicine acupuncture which consisted of manual twisting of the needle at points accompanied by electrical stimulation of distal points; or acupuncture with sham acupoints and sham (weak) electrical stimulation. The outcome measures used in the study were weighted equally and included pain intensity, pain duration, analgesia use, visual analogue scales and neck disability index. It was found that both the Chinese acupuncture and the sham treatments significantly reduced each of these subjective measures. The patients were also assessed using objectives measures, which consisted of range of movement and pain threshold assessments. It was found that neither group improved from the baseline measurements for either measure. It is possible that the small sample size may have limited this study, although it would appear from the results that Chinese acupuncture is not effective at treating neck pain. These results must be treated with caution when considering acupuncture as a whole as the methodology of Chinese acupuncture is somewhat different to other forms, and failure of Chinese acupuncture does not necessarily guarantee failure overall. The credibility of the control used in this study is possibly higher than that of the previous two studies, as the use of sham acupuncture more closely mimics the process of the true acupuncture than electrical stimulation of points. Birch and Jamison 1998: Controlled trial of Japanese acupuncture for chronic myofascial neck pain: assessment of specific and non-specific effects of treatment – The Clinical Journal of Pain 1998 Sep; 14(3):248-255 The study by Birch and Jamison (1998) found that Japanese acupuncture coupled with heat treatment was moderately successful in removing pain. This study was also a randomised, single blind, placebo controlled study. There is no mention of where the study participants were selected from nor of their age. There is also no mention of the criteria for selection of the participants other than that they suffered chronic myofascial neck pain. This may lead to a limitation of the applicability of the study to practice as it is unclear how relevant the findings are to various populations. The outcome measures in the study the McGill Pain Questionnaire Short Form, the Short Form Health Survey and Symptom Checklist 90. Factors which predicted benefit were also assessed in the study, such as experience, beliefs about acupuncture and painfulness of the treatment. The patients were randomly assigned to one of two groups. One group received Japanese acupuncture, while the placebo group received acupuncture in sites which were not considered relevant to cervical pain. It was found that the group which received the acupuncture had significantly pre/post acupuncture pain levels than the placebo group. However in the baseline results that the group which received acupuncture had a higher mean number of previous acupuncture treatments than the placebo groups. The study also found that previous experience is an indicator of success for acupuncture, therefore this may have influenced the overall result of the study. The pain assessment measures used were also subjective measures, therefore these may have been influenced by the previous experiences and beliefs of the participants. Thomas et al1991: A comparative study of diazepam and acupuncture in patients with osteoarthritis pain: a placebo controlled study – The American Journal of Chinese Medicine 1991:19(2):95-100 The study by Thomas et al (1991) found that while acupuncture was more effective than the placebo diazepam, there was not a significantly better effect observed in acupuncture than when participants received diazepam or sham acupuncture. The study was a randomised, controlled trial, which was conducted in patients between 42-77 years old. This makes the sample a significantly older age group than many of the other studies into acupuncture for neck pain. The recruitment criteria in the study were to have osteoarthritis of the cervical spine which had been present for at least six months, and a total of 44 participants were selected and completed the study. The patients were randomly assigned to one of four different treatment groups. Two groups were treated with acupuncture alone, one receiving actual acupuncture while the other received sham acupuncture. The third and fourth groups received only diazepam and no acupuncture, although one of these groups received placebo diazepam. The outcome of measurement was the presence of pain, which was measured using separate visual analogue scales. All four treatments were found to create some alleviation of the pain. Acupuncture was found to alleviate the pain better than the placebo diazepam, but there were found to be no significant differences between the pain alleviation in the diazepam or sham acupuncture groups. One possible reason for the lack of observed differences could be related to the type of neck pain which was present. This study was far more specific than other studies, as it regarded only neck pain caused by osteoarthritis. It could be that the underlying physiological mechanisms were the reason for the difference in effectiveness observed in this study compared to other similar studies into more general neck pain. 3.2.2: Acupuncture versus other interventions Witt et al 2006: Acupuncture for patients with chronic neck pain – Pain 2006 Nov;125(1-2):98-106 The study by Witt et al (2006) found that the addition of acupuncture to the routine care of patients was associated with improvements in neck pain and disability when compared to the routine treatment alone. The study was carried out as a randomised controlled trial in multiple treatment centres across Germany. Patients were all aged over 18 years, although there is no mention in the study as to the maximum age of participants. The criteria on which the participants were selected involved having a clinical diagnosis of chronic neck pain which was no more than six months old. Exclusion criteria were applied in order to select for those without complications to the diagnosis. In total 3766 participants completed the randomised control, and a further 10395 took part in a non-randomised cohort study of acupuncture. The participants of the randomised study were allocated to one of two groups, where they either received standard medical care for their neck pain or they received standard medical care and also acupuncture. The acupuncture was carried out in up to 15 sessions over a three month period. The outcomes which were used for measurement in the trial were neck pain and disability, which were measured at three months using standardised questionnaires. The secondary measure in the study was the reduction in neck pain and disability in proportion to the baseline assessment. The final outcome of the study was that those receiving acupuncture showed better outcomes for disability and quality of life than those receiving standard treatment alone. With regards specifically to pain however the group which received acupuncture showed only a marginal improvement over the group which did not receive acupuncture. The large scale of this study increases the overall reliability, and the results suggest that the use of acupuncture in addition to standard treatment would be beneficial to the patient, although there are no added benefits relating specifically to pain relief. David et al 1998: Chronic neck pain: a comparison of acupuncture treatment and physiotherapy – British Journal of Rheumatology 1998 Oct;37(10):1118-1122 The study by David et al (1998) compared the effectiveness of acupuncture in comparison to physiotherapy for treatment of neck pain. The study found that both were beneficial but it remained unclear as to the overall improvement which the acupuncture held over the patient receiving no treatment. The study was a randomised trial, although there was no control, and it was not blind. The participants were all aged 18 to 75 years old, and were referred from GP practices in the UK. The patients were selected on the basis of having neck pain and having not received acupuncture or physiotherapy previously for neck pain. Certain medical conditions which may affect the outcome were also used as exclusion criteria in order to improve the reliability of the study. In total, 70 participants completed the study; 33 of these receiving acupuncture treatment and the remainder receiving physiotherapy. The participants were assessed at the baseline, after six weeks of treatment, and at a six month follow-up. The outcome measures were based on a visual analogue scale of pain and the Northwick Park neck pain questionnaire, along with an assessment of the neck range of movement. Initially, the acupuncture group were shown to make less improvement than the physiotherapy group in terms of their visual assessment scores. Both groups were shown to have some deterioration in improvement over six months when compared to the results at six weeks. There was very little difference observed between the improvements in pain between the two groups, although using the general health questionnaire it was found that those who received physiotherapy made far larger improvements over all. In terms of neck pain however the study suggests that acupuncture should be as effective as physiotherapy. It is unclear how much more effective acupuncture may be in comparison to the patient receiving no treatment, as there was no control included in the study in which no treatment was given. Overall however the study suggests that acupuncture would be an effective treatment to use for relief of neck pain. Irnich et al 2001: Randomised trial of acupuncture compared with conventional massage and ‘sham’ laser acupuncture for treatment of chronic neck pain – BMJ 2001 Jun 30;322(7302):1574-1578 The study by Inrich et al (2001) is possibly the most useful study available for assessing the effectiveness of acupuncture in treating neck pain. The study made a comparison of acupuncture as a treatment against traditional massage, however it also included a placebo group which received sham acupuncture. The study showed that acupuncture is an effective short term treatment for neck pain but that the long term effects of the treatment are limited. The study was a randomised, controlled study in which the control took the form of both placebo and alternative treatment. The study was conducted in three outpatient departments in Germany, with participants aged 18 to 85 years old. The inclusion criteria for the study were having neck pain which had lasted for more than a month, and not having received any treatment in the two weeks prior to the study. In all 177 participants completed the study. These were randomly assigned to one of the three treatments, which they received a total of five times over three weeks. The primary outcome measures in the study were the change in the maximum pain related to motion at one week and at five weeks. Secondary outcome measures were the range of motion and the pain threshold, which were both included as objective measures. At the one week point after the five treatments had been received the acupuncture group showed significantly better improvement than the massage group. However there was shown to be no significant difference between the acupuncture group and the placebo group. This may not be entirely accurate however, as the acupuncture group showed greater improvement in the secondary measures. As the secondary measures were objective while the primary measure was subjective this would suggest that the placebo group only perceived that they had less pain due to the belief that they were receiving acupuncture. Clinically this may signify that there were in fact greater improvements in those receiving acupuncture . Salter et al 2006: Acupuncture for chronic neck pain: a pilot for a randomised controlled trial – BMC Musculoskeletal Disorders 2006 Dec 9;7(99):Epub The trial by Salter et al (2006) was designed to be a pilot for a larger randomised controlled trial. Therefore the data which is included in the pilot is somewhat incomplete. There are however trends in the data which may signify the possible findings in the complete study. The trend in the available data show that patients who received acupuncture had higher levels of satisfaction than those who received GP care alone. The study highlighted that the main concerns which related to acupuncture treatment were worsening of symptoms initially in some patients. Once completed the study should present data from a large sample which will be used in order to assess the overall effectiveness of acupuncture on a large scale. 3.3: STRICTA score analysis In terms of the STRICTA score, much of the current literature is lacking with regards to the details needed to obtain all of the points on the scale. The items which are most frequently missing relate to the needling details and the practitioner background. Most of the literature reviewed here has the details of the other points although some lack in this also. The details relating to the clinician who performed the procedure are usually not present in the studies detailed here, and that has serious implications for the relevance of the results as it is difficult to assess whether this would be different depending on whether the procedures were performed by an experienced clinician or not. Read More