From original paper and comments ...

This was posted on another list.
These are extract from the original paper, together with comments by author, Peter Moran.


"Acupuncture was administered in 340 outpatient practices by physicians of various specializations who had at least 140 hours of acupuncture training:"


"Sham acupuncture on either side of the lateral part of the back and on the lower limbs was also standardized, avoiding all known verum points or meridians. As with verum acupuncture, 14 to 20 needles were inserted, but superficially (1-3 mm) and without stimulation."


"During acupuncture treatment, communication with the patient was limited to necessary explanations to avoid unblinding the patient by suggestive remarks. Patients in all 3 groups were informed before randomization that acupuncture would be offered after completion of the trial.
------

Patient blinding was assessed at the 6-month interview by asking whether their physician had informed them of their allocation and, if not, by asking the method of acupuncture and how certain they were of their response.14

-------
Blinding seems to have been maintained: most patients did not correctly identify or did not know which form they had received (Table 3)."


Comment: Amazing that they were able to maintain a high level of blinding of
patients, when the 1160 patients were diffused so widely.


"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. "



Comment: So, quite a wide range of treatments were used in the
"conventional only" cohort. Perhaps not quite "ho-hum treatment that has
probably already been tried in most of the same patients", as I described
it in my previous post, but probably consistent with placebo treatments of
varying degrees of credibility with the patient? A matter of opinion, I
guess.



"First, the unexpected finding of similar effectiveness of sham and verum acupuncture forces us to question the underlying action mechanism of acupuncture and to ask whether the emphasis placed on learning the traditional Chinese acupuncture points may be superfluous. Second, while all randomized trials and meta-analyses to date have failed to show a clear advantage of acupuncture over conventional therapy for chronic low back pain, our findings demonstrate significant superiority."

-----------------

"The underlying mechanism may be a kind of superplacebo effect produced by placebo and all nonspecific factors working together. Nevertheless, the effectiveness of acupuncture cannot be attributed merely to a placebo effect because there is no reason to believe that the action mechanism of conventional therapy is the result solely of the placebo effect."


Comment: There is no reason why the majority of any symptom relief from a
treatment cannot be due to placebo influences that will vary greatly in
strength depending on many factors. They have also not considered the
possible contribution of reporting biases to their results, as this section
of the study was of necessity not blinded.





The discussion is a bit confused. Perhaps there are some problems with
translation, but the authors seem to be also seriously taken aback by
findings that undermine the credibility of traditional acupuncture. They
don't know what to make of it while also clinging to prior beliefs.


As the study was designed to vindicate traditional acupuncture rather than
demonstrate its actual utility within the medical system, no information is
provided as to more objective measurements of its effectiveness such as
getting patients back to work, and its effect upon the consumption of
medications and other medical resources.


Peter Moran

Alert Webmaster & Moderators