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Akupunktur bei Rückenschmerzen

 
 

Im Jahre 2000 wurde in England die Akupunktur zur Behandlung chronischer Rückenschmerzen zugelassen. 

Erstaunlicherweise bieten 47% der praktischen Ärzte in England Akupunkturbehandlungen an.

Die kontroverse Diskussion über der Nachweis der Wirksamkeit der Akupunktur ist natürlich auch in England im vollen Gange. Hier ein Leserbrief im British Medical Journal (bmj), in dem auf ein Cochrane-Review zur Wirksamkeit der Akupunktur bei chronischen Rückenschmerzen verwiesen wird.

In diesem Review ergaben sich Hinweise für die Effektivität der Akupunktur bei Rückenschmerzen, aber sie waren statistisch nicht schlüssig und nicht geeignet für eine allgemeine Empfehlung.

"Main results: Eleven trials were included. The methodological quality was low. Only two trials were of high quality. Three trials compared acupuncture to no treatment, which were of low methodological quality and provide conflicting evidence. There was moderate evidence from two trials that acupuncture is not more effective than trigger point injection or transcutaneous electrical nerve stimulation (TENS). There was limited evidence from eight trials that acupuncture is not more effective than placebo or sham acupuncture for the treatment of chronic low back pain.

Reviewers' conclusions: The evidence summarised in this systematic review does not indicate that acupuncture is effective for the treatment of back pain.

Citation: Tulder MW van, Cherkin DC, Berman B, Lao L, Koes BW. Acupuncture for low back pain (Cochrane Review). In: The Cochrane Library, 1, 2002. Oxford: Update Software."

 

Zum Cochrane Review kommt Ihr über diesen link:

http://www.update-software.com/abstracts/ab001351.htm

Is BMA approval of acupuncture for back pain evidence based? bmj, 16 July 2000  

The BMA report recently referred to in the BMJ1 concludes that acupuncture should be made more widely available to users of the British National Health Service, and that general practice physicians should receive some training in this technique.

The BMA report appears to base its conclusion on the following: a) the evidence showing that "acupuncture is more effective than control interventions for back pain, nausea and vomiting, migraine and dental pain"; b) the fact that 47% of general practitioners have arranged for their patients to receive acupuncture treatment; and c) the wish of 46% of those professionals to receive further training in acupuncture in order to treat their own patients.

The available evidence on the effectiveness of acupuncture in the treatment of back pain appears to have been misinterpreted. The Cochrane Collaboration Back Review Group has recently published a major systematic review of the effectiveness of acupuncture in the treatment of low back pain. This review followed a rigorous methodology and an exhaustive search for information (i.e. a native Chinese researcher participated in the review in order to evaluate possible clinical trials published in that language, although there were none).

Its results showed that there was scientific evidence on the effectiveness of acupuncture for the treatment of low back pain, but it was inconclusive and could not serve as a basis for recommending it. This was consistent with the results of systematic reviews done in the past, and with a randomized trial which compared its effectiveness with that of massage and self-care education.

Although scientific evidence in this respect has not changed much in the last nine years, public and physician opinion does appear to have changed, due to other reasons. The desire to comply with public opinion can lead to the adoption of decisions that do not have sufficient scientific support. However, the establishment of a double standard for the approval or rejection of a treatment technique, bowing to the pressure of public opinion and not taking into account evidence based recommendations, would be harmful to the public's health and to the economy of the National Health System.

Additionally, in the long term it could also be harmful to the types of treatment approved with the lower standard, and even to the credibility of the institutions that recommend its use. Clinical practice is not always based on scientific evidence and the search for an efficient use of available resources. The interest of general practitioners in receiving training in acupuncture could be due to the publication of scientific studies that demonstrate its effectiveness. However, since this is not so, at least in the area of back pain, it may be due to other reasons.

Until just a few decades ago, patients were convinced of the effectiveness of leeches for the treatment of infectious diseases, physicians prescribed them, and apothecaries sold them. Nevertheless, in spite of public demand and medical interest, evidence of the efficacy, safety and cost-effectiveness of the treatment was also lacking. This lesson from the past should be kept in mind.

Francisco M. Kovacs, MD, PhD María Teresa Gil del Real, MPH, PhD Scientific Department, Kovacs Foundation, Palma de Mallorca, Spain Members of the Management Committee of the COST B4 Program on Unconventional Medicine

REFERENCES: 1. Silvert M. News. Acupuncture wins BMA approval. BMJ 2000 (1 July); 321:11.

2. van Tulder MW, Cherkin DC, Berman B, et al. The effectiveness of acupuncture in the management of acute and chronic low back pain. A systematic review within the framework of the Cochrane Collaboration Back Review Group. Spine 1999; 24(11): 1113-23.

3. Ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain: A criteria-based meta-analysis. J Clin Epidemiol 1990;43: 1191-9.

4. Cherkin DC, Eisenberg D, Kaptchuk T, et al. A randomized trial comparing acupuncture, therapeutic massage and self-care education for chronic low back pain. Presented at the Fourth International Forum for Primary Care Research on Low Back Pain. Eilat. Israel. 2000. As yet unpublished.

 

Akupunktur bei chronischem Schmerz

 
Eine Meta-Analyse von 10 Studien ergab bei insgesamt schlechter statistischer Qualität widersprüchliche und unbefriedigende Ergebnisse für alle genannten Verfahren.

Eine einzige kontrollierte randomisierte Studie ergab Hinweise dafür, dass elektrische Nervenstimulation eine Schmerzlinderung bei Patienten mit myofaszialen schmerzen für ca. 4 Wochen bewirken kann.

 Clin J Pain Dec 2001; 17(4 Suppl):S105-13
Acupuncture, transcutaneous electrical nerve stimulation, and laser therapy in chronic pain.

Fargas-Babjak

Department of Anesthesia, McMaster University, Hamilton, Ontario, Canada. babjaka@mcmaster.ca

OBJECTIVE: The purpose of this review was to determine how effective acupuncture, transcutaneous electrical nerve stimulation, acupuncture-like transcutaneous nerve stimulation, laser therapy, electrical nerve stimulation, and neuroreflexotherapy are in the management of chronic pain. METHODOLOGY: The literature search identified six systematic reviews of the literature and four randomized controlled trials to provide evidence for this review. RESULTS: The systematic reviews included different methodologies and heterogeneity of study groups, but studies were generally of poor methodology. Although sham acupuncture may have analgesic effects, it was used as a control in many studies. CONCLUSIONS: In general, the evidence was contradictory or inadequate, reflecting poor study methodologies. No positive conclusion could be reached for acupuncture, transcutaneous electrical nerve stimulation, acupuncture-like transcutaneous nerve stimulation, laser therapy, or neuroreflexotherapy. A single randomized controlled trial provided limited evidence (level 3) that electrical nerve stimulation is effective for pain relief in myofascial pain syndrome for up to 4 weeks, but further study in humans is needed. Future randomized controlled trials and systematic reviews should include subgroup analyses of sham acupuncture and inert placebos as controls.  

  Akupunktur bei chronischen Kopfschmerzen

10 nicht- randomisierte Studien, 10 randomisierte und 10 zusammengesetzte Übersichten wurden verglichen. Die nicht-randomisierten Studien bestätigten die Ergebnisse der randomisierten Studien (..."that the treatment is likely to be effective"), ohne jedoch zusätzliche Informationen über die Langzeitwirkung, Prognose oder Nebenwirkungen zu liefern. Auch zu diesem Theme gibt es ein Cochrane-Review:

Main results: Twenty-six trials including a total of 1151 patients (median, 37; range, 10-150) met the inclusion criteria. Sixteen trials were conducted among patients with migraine, six among patients with tension-type headache, and four among patients with various types of headaches. The majority of trials had methodological and/or reporting shortcomings. In eight of the 16 trials comparing true and sham (placebo) acupuncture in migraine and tension-type headache patients, true acupuncture was reported to be significantly superior; in four trials there was a trend in favor of true acupuncture; and in two trials there was no difference between the two interventions. (Two trials were uninterpretable.) The 10 trials comparing acupuncture with other forms of treatment yielded contradictory results.

Reviewers' conclusions: Overall, the existing evidence supports the value of acupuncture for the treatment of idiopathic headaches. However, the quality and amount of evidence are not fully convincing. There is an urgent need for well-planned, large-scale studies to assess the effectiveness and cost-effectiveness of acupuncture under real-life conditions.

Zum Cochrane Review kommt Ihr über diesen link:

http://www.update-software.com/abstracts/ab001218.htm

J Clin Epidemiol Jan 2002; 55(1):77-85
Should systematic reviews include non-randomized and uncontrolled studies? The case of acupuncture for chronic headache.

Linde, Scholz, Melchart, Willich

Institute for Social Medicine & Epidemiology, Charité Hospital, Humboldt-Universität, 10098, Berlin, Germany

We aimed to investigate: (1) whether patient and intervention characteristics, design-independent quality aspects, and response rates differ between randomized and non-randomized trials of acupuncture for chronic headache; (2) whether non-randomized studies provide useful additional information (regarding long-term effects, prognostic factors, adverse effects, and generalizability); (3) reasons for potential differences in response rates. Studies including at least five patients and reporting clinical outcome data were identified through searches in Medline, Embase, the Cochrane Controlled Trials Register, other databases and checking of bibliographies. Twenty-four randomized trials and 35 non-randomized studies (five non-randomized controlled cohort studies, 10 prospective uncontrolled studies, 10 case series, and 10 cross-sectional surveys) met the inclusion criteria. Studies were heterogeneous regarding patients, interventions, outcome measurements and results. On average, randomized trials had smaller sample sizes, met more quality criteria, and had lower response rates (0.59 [95% confidence interval 0.48-0.69] vs. 0.78 [0.72-0.83]). Whether randomized or not, studies meeting more quality criteria had lower response rates. Non-randomized studies did not have significantly longer follow-up periods, three included an analysis of prognostic variables, only one reported on adverse effects, and the degree of generalizability was unclear. In the case of acupuncture for chronic headache, non-randomized studies confirmed the finding of a systematic review of randomized trials that the treatment is likely to be effective but provided little relevant additional information on long-term effects, prognostic factors, and adverse effects.

  Akupunktur in der Schlaganfallrehabilitation

In dieser chinesischen Studie zeigte die Akupunktur keinen zusätzlichen Nutzen in der motorischen Rehabilitation nach Schlaganfall. Durchschnittlich wurden die Patienten 35x (!) genadelt an 10 Hauptpunkten. 

Eine Schädelakupunktur nach Yamamoto, die sich in früheren Studien als effektiv gezeigt hatte, wurde hier offensichtlich nicht durchgeführt.

 Stroke Jan 2002; 33(1):186-94
 Does acupuncture have additional value to standard poststroke motor rehabilitation?
Sze, Wong, Yi, Woo

Department of Medicine and Geriatrics (F.K.-H.S.), Shatin Hospital, Hong Kong.

Background and Purpose- A significant number of patients remain severely disabled after stroke despite rehabilitation with standard treatment modalities. Acupuncture has been reported as an alternative modality. This study aims to examine whether acupuncture has additional value to standard poststroke motor rehabilitation. METHODS: A prospective randomized controlled trial (RCT) was carried out in a stroke rehabilitation unit in Hong Kong. One hundred six Chinese patients with moderate or severe functional impairment were included at days 3 to 15 after acute stroke. They were stratified into the moderate and the severe groups before randomization into the control arm receiving standard modalities of treatment, which included physiotherapy, occupational and speech therapy, and skilled medical and nursing care, and the intervention arm receiving in addition traditional Chinese manual acupuncture. A mean of 35 acupuncture sessions on 10 main acupoints were performed over a 10-week period. Outcome measures included Fugl-Meyer assessment, Barthel Index, and Functional Independence Measure, respectively, at weeks 0, 5, and 10, performed by blinded assessors. RESULTS: At baseline, patients in each arm were comparable in all important prognostic characteristics. No statistically significant differences were observed between the 2 arms for any of the outcome measures at week 10 or outcome changes over time. CONCLUSIONS: Traditional Chinese manual acupuncture on the body has no additional value to standard poststroke motor rehabilitation.  

Akupunktur bei Schulter-Nackenschmerzen

Diese beiden Studien zeigen einen positiven Effekt der Akupunktur bei schmerzhafter Schultersteife und bei chronischen Nackenschmerzen.

Kommentare im bmj

What is already known on this topic
Acupuncture is a widespread complementary treatment

Evidence from trials have given conflicting results on its use in the treatment of neck pain because of methodological shortcomings and because effects were compared either with alternative treatments or with different sham procedures imitating acupuncture, but not both

What this study adds
Compared with sham laser acupuncture and massage, needle acupuncture has beneficial effects on mobility and pain related to motion in patients with chronic neck pain.

Acupuncture was clearly more effective than massage, but differences were not always significant compared with sham laser acupuncture

Acupuncture was the best treatment for patients with the myofascial syndrome and those who had had pain for longer than five years  

 

Hong Kong Med J Dec 2001; 7(4):381-91
Acupuncture for frozen shoulder.
Sun, Chan, Lo, Fong
Department of Anaesthesiology and Operating Theatre Services, Kwong Wah Hospital, 25 Waterloo Road, Kowloon, Hong Kong.

This randomised controlled trial was undertaken to evaluate the effectiveness of acupuncture as a treatment for frozen shoulder. Thirty-five patients with a diagnosis of frozen shoulder were randomly allocated to an exercise group or an exercise plus acupuncture group and treated for a period of 6 weeks. Functional mobility, power, and pain were assessed by a blinded assessor using the Constant Shoulder Assessment, at baseline, 6 weeks and 20 weeks. Analysis was based on the intention-to-treat principle. Compared with the exercise group, the exercise plus acupuncture group experienced significantly greater improvement with treatment. Improvements in scores by 39.8% (standard deviation, 27.1) and 76.4% (55.0) were seen for the exercise and the exercise plus acupuncture groups, respectively at 6 weeks (P=0.048), and were sustained at the 20-week re-assessment (40.3% [26.7] and 77.2% [54.0], respectively; P=0.025). We conclude that the combination of acupuncture with shoulder exercise may offer effective treatment for frozen shoulder.

Bmj-Papers

Randomised trial of acupuncture compared with conventional massage and "sham" laser acupuncture for treatment of chronic neck pain

Dominik Irnich, research fellow, a Nicolas Behrens, research fellow, b Holger Molzen, research fellow, d Achim König, consultant orthopaedic surgeon, d Jochen Gleditsch, consultant pain therapy, a Martin Krauss, statistician, c Malte Natalis, consultant orthopaedic surgeon, d Edward Senn, professor of physical medicine and rehabilitation, e Antje Beyer, head of pain unit, a Peter Schöps, head of pain unit. b

a Department of Anaesthesiology, Ludwig-Maximilians University, 81377 Munich, Germany, b Department of Physical Medicine and Rehabilitation, Ludwig-Maximilians University, c Biometric Center for Therapeutic Studies, 80336 Munich, Germany, d Department of Orthopaedics, University of Würzburg, 97074 Würzburg, Germany, e Reha Klinik Bellikon, 5454 Bellikon, Switzerland

Correspondence to: D Irnich Dominik.Irnich@lrz.uni-muenchen.de

Objectives: To compare the efficacy of acupuncture and conventional massage for the treatment of chronic neck pain.
Design: Prospective, randomised, placebo controlled trial.
Setting: Three outpatient departments in Germany.
Participants: 177 patients aged 18-85 years with chronic neck pain.
Interventions: Patients were randomly allocated to five treatments over three weeks with acupuncture (56), massage (60), or "sham" laser acupuncture (61).
Main outcome measures: Primary outcome measure: maximum pain related to motion (visual analogue scale) irrespective of direction of movement one week after treatment. Secondary outcome measures: range of motion (3D ultrasound real time motion analyser), pain related to movement in six directions (visual analogue scale), pressure pain threshold (pressure algometer), changes of spontaneous pain, motion related pain, global complaints (seven point scale), and quality of life (SF-36). Assessments were performed before, during, and one week and three months after treatment. Patients' beliefs in treatment were assessed.
Results: One week after five treatments the acupuncture group showed a significantly greater improvement in motion related pain compared with massage (difference 24.22 (95% confidence interval 16.5 to 31.9), P=0.0052) but not compared with sham laser (17.28 (10.0 to 24.6), P=0.327). Differences between acupuncture and massage or sham laser were greater in the subgroup who had had pain for longer than five years (n=75) and in patients with myofascial pain syndrome (n=129). The acupuncture group had the best results in most secondary outcome measures. There were no differences in patients' beliefs in treatment.
Conclusions: Acupuncture is an effective short term treatment for patients with chronic neck pain, but there is only limited evidence for long term effects after five treatments.



 

Nebenwirkungen der Akupunktur

 
In einer britischen prospektiven Studie wurden Nebenwirkungen bei 34000 Akupunktur- behandlungen analysiert. Signifikante geringere und vorübergehende Nebenwirkungen wurden in einer Häufigkeit von 0,13% beobachtet. Schwerwiegende Nebenwirkungen traten nicht auf. Acupunct Med Dec 2001; 19(2):93-102
A prospective survey of adverse events and treatment reactions following 34,000 consultations with professional acupuncturists.

MacPherson, Thomas, Walters, Fitter

Foundation for Traditional Chinese Medicine, York. hugh@ftcm.org.uk

The paper describes the type and frequency of adverse events and transicnt reactions following consultations with professional acupuncturists. In a postal survey, involving 1,848 professional acupuncturists, all of whom were members of the British Acupuncture Council and practising in the UK, details of adverse events and transient reactions following treatment were recorded on standardised self-report forms. A sample size of 30,000 treatments was sought, and piloting indicated that a four-week period was required. Practitioners also provided information on themselves, including age, sex, length of training and years of practice. A total of 574 practitioners responded. 31% of the total population. These practitioners reported on adverse events and transient reactions associated with 34,407 treatments. No serious adverse events were reported, where these were defined as requiring hospital admission, prolonging hospital stays, permanently disabling, or resulting in death (95% CI: 0 to 1.1 per 10,000 treatments). A total of 43 significant minor adverse events were reported, a rate of 1.3 per 1,000 treatments (95% CI: 0.9 to 1.7). These included severe nausea and actual fainting (12), unexpected, severe and prolonged aggravation of symptoms (7), prolonged and unacceptable pain and bruising (5) and psychological and emotional reactions (4). There were three avoidable events: two patients had needles left in by mistake, and one patient had moxa burns to the skin, also caused by practitioner error. The acupuncturists also recorded 10,920 mild transient reactions occurring in 5136 treatments. 15% (95% CI: 14.6 to 15.3) of the 34,407 total. In terms of local reactions, there were reports of mild bruising (1.7%), pain (1.2%) and bleeding (0.4%). Practitioners reported that patients experienced an aggravation of existing symptoms after 2.8% of treatments. The most common mild transient reactions to treatment were feeling relaxed (11.9%) and feeling energised (6.6%). In this prospective survey of 34,407 treatments, practitioners reported no serious adverse events. This conclusion was based on data collected from one in three members of the British Acupuncture Council. Given that the whole membership delivers between one and a half and two million treatments a year, this is important evidence on public health and safety. When compared with medication routinely prescribed in primary care, the results suggest that acupuncture is a relatively safe treatment modality.  

Akupunktur bei Kokainabhängigkeit

Bei diesen kontrollierten amerikanischen  Studien mit Kokainabhängigen konnte keine Effektivität der Verum-Ohrakupunktur als alleinige Behandlungsmaßnahme nachgewiesen werden.

 

 

 

 

 

 

 

 

 

Demgegenüber zeigte diese amerikanische Arbeit eine Wirksamkeit der Akupunktur bei Kokainabhängigen. 

Der Grund für die widersprüchlichen Ergebnisse bleibt unklar. Leider enthalten die abstracts auch keine Angaben über die Punktwahl (NADA?).

 JAMA Jan 2002; 287(1):55-63
Acupuncture for the treatment of cocaine addiction: a randomized controlled trial.

Margolin, Kleber, Avants, Konefal, Gawin, Stark, Sorensen, Midkiff, Wells, Jackson, Bullock, Culliton, Boles, Vaughan

Yale University School of Medicine, Substance Abuse Center, 34 Park St, New Haven, CT 06519, USA. arthur.margolin@yale.edu

CONTEXT: Auricular acupuncture is widely used to treat cocaine addiction in the United States and Europe. However, evidence from controlled studies regarding this treatment's effectiveness has been inconsistent. OBJECTIVE: To investigate the effectiveness of auricular acupuncture as a treatment for cocaine addiction. DESIGN: Randomized, controlled, single-blind clinical trial conducted from November 1996 to April 1999. SETTING: Six community-based clinics in the United States: 3 hospital-affiliated clinics and 3 methadone maintenance programs. PATIENTS: Six hundred twenty cocaine-dependent adult patients (mean age, 38.8 years; 69.2% men); 412 used cocaine only and 208 used both opiates and cocaine and were receiving methadone maintenance. INTERVENTION: Patients were randomly assigned to receive auricular acupuncture (n = 222), a needle-insertion control condition (n = 203), or a relaxation control condition (n = 195). Treatments were offered 5 times weekly for 8 weeks. Concurrent drug counseling was also offered to patients in all conditions. MAIN OUTCOME MEASURES: Cocaine use during treatment and at the 3- and 6-month postrandomization follow-up based on urine toxicology screens; retention in treatment. RESULTS: Intent-to-treat analysis of urine samples showed a significant overall reduction in cocaine use (odds ratio, 1.40; 95% confidence interval, 1.11-1.74; P =.002) but no differences by treatment condition (P =.90 for acupuncture vs both control conditions). There were also no differences between the conditions in treatment retention (44%-46% for the full 8 weeks). Counseling sessions in all 3 conditions were poorly attended. CONCLUSIONS: Within the clinical context of this study, acupuncture was not more effective than a needle insertion or relaxation control in reducing cocaine use. Our study does not support the use of acupuncture as a stand-alone treatment for cocaine addiction or in contexts in which patients receive only minimal concurrent psychosocial treatment. Research will be needed to examine acupuncture's contribution to addiction treatment when provided in an ancillary role.  
 
J Subst Abuse Treat 1999 Jan;16(1):31-8
Auricular acupuncture in the treatment of cocaine abuse. A study of efficacy and dosing.

Bullock ML, Kiresuk TJ, Pheley AM, Culliton PD, Lenz SK.
Center for Addiction and Alternative Medicine Research, Minneapolis, MN, USA.

A single-blind, randomized, placebo-controlled study was performed to evaluate auricular acupuncture (AAc) in the treatment of cocaine addiction. Two linked but concurrent studies were done. In Study 1, residential clients (N = 236) were randomized to true acupuncture (Ac), sham Ac, and conventional treatment without Ac. Treatment group subjects received Ac at three ear points considered to be specific for the treatment of substance abuse (SA). Control subjects received three nonspecific (sham) points. In Study 2, day treatment clients (N = 202) were randomized to one of three dose levels of true Ac (28, 16, or 8 treatments). Subjects received Ac at five, rather than three, specific ear points. Nonspecific (sham) points were not used in Study 2. With rare exception, the data failed to identify significant treatment differences among the true and sham Ac, and psychosocial groups. Furthermore, no differences were observed among the three dose levels of true Ac.
Arch Intern Med 2000 Aug 14-28;160(15):2305-12

A randomized controlled trial of auricular acupuncture for cocaine dependence.

Avants SK, Margolin A, Holford TR, Kosten TR.

Substance Abuse Center, Yale University School of Medicine, New Haven, CT 06519, USA.

BACKGROUND: Partly because of a lack of a conventional, effective treatment for cocaine addiction, auricular acupuncture is used to treat this disorder in numerous drug treatment facilities across the country for both primary cocaine-dependent and opiate-dependent populations. OBJECTIVE: To evaluate the effectiveness of auricular acupuncture for the treatment of cocaine addiction. METHODS: Eighty-two cocaine-dependent, methadone-maintained patients were randomly assigned to 1 of 3 conditions: auricular acupuncture, a needle-insertion control condition, or a no-needle relaxation control. Treatment sessions were provided 5 times weekly for 8 weeks. The primary outcome was cocaine use assessed by 3-times-weekly urine toxicology screens. RESULTS: Longitudinal analysis of the urine data for the intent-to-treat sample showed that patients assigned to acupuncture were significantly more likely to provide cocaine-negative urine samples relative to both the relaxation control (odds ratio, 3.41; 95% confidence interval, 1.33-8.72; P =. 01) and the needle-insertion control (odds ratio, 2.40; 95% confidence interval, 1.00-5.75; P =.05). CONCLUSIONS: Findings from the current study suggest that acupuncture shows promise for the treatment of cocaine dependence. Further investigation of this treatment modality appears to be warranted.

 

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