Treatment of low back pain by acupressure and physical therapy: randomised controlled trial
BMJ 2006; 332 doi: https://doi.org/10.1136/bmj.38744.672616.AE (Published 23 March 2006) Cite this as: BMJ 2006;332:696All rapid responses
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I have read over this thread, and I find the comments made by Tony
Hsiu-Hsi Chen to be extremely biased. He obviously did not understand
fully the statements made by Mr. White and thus did not address their
implications. While he addressed the fact that the patients in the study
did not receive care at the same facility (or would be difficult to
determine), he made no mention of the major point Mt. White made: namely,
that the patients had undertaken prior physical therapy-- and were perhaps
treated with the same modalities in the study. If it did not work the
first time, it probably won't the second time? It is a pity that Dr. Chen
misses this obvoius point. This represents, in my mind, a major design
flaw.
I do recognize your point, Dr. Chen, that you wanted to investigate
treatment outcomes on those with chronic back pain, and precisely those
patients would have most likely already undergone PT of some kind.
However, at the very least, this issue (stated above) should have been
acknowledged in your study.
In addition, the point raised by Mr. Allen is also a valid one. You
did not standardize the control group treatment. Hello? Of course
different patients may require different modalities based on presenting
symptoms and signs. However, if you are to leave the treatment to the
discretion of the therapist, then your control group is really not a
control group at all. A better idea would be to recruit patients who
require the same PT treatment, and use them as your control group.
Please learn to design a study better before conducting one.
Performing a study in this manner really serves no good, in my mind,
as both sides (pro-acupressure and against acupressure) will
silmultaneously arrive at opposite conclusions. You confuse the average
person, perpetuate sub-par science, and do a disservice to the modality
you are examining.
Competing interests:
None declared
Competing interests: No competing interests
VIA ELECTRONIC MAIL AT WWW.BMJ.BMJJOURNALS.COM
Dear Sir or Madam,
After receiving some very beneficial treatment in acupressure, my
wife and I decided to research the responses of those in the medical
community towards this alternative method for treatment towards certain
illnesses and physical pain. For your reference, I am a former United
States Army Captain and graduate of the United States Military Academy at
West Point, who suffered severe lower back and knee injury during my
military service. I have tried numerous treatments from physical therapy,
surgery, chiropractics, diet and lifestyle changes, to appropriate pain
medications all of which produced relative results with negligible long
term benefits.
We recently consulted with Hsieh, senior therapist and co-author of
“Treatment of low back pain by acupressure and physical therapy:
randomized controlled trial.” One of the primary reasons we visited with
her was due to her complementary knowledge in Western medicine. She is
also a medical doctor who specializes in both the Neurology and Internal
Medicine Departments at Kaohsiung, Taiwan. And after receiving a
concentrated series of acupressure from this senior therapist – twice
daily for a period of ten days – I honestly feel a significant amount of
pain relief and mobility in both my lower back and knees. In fact, the
treatment occurred over two months ago, and I still feel a significant
improvement from my original condition.
I am concerned over the questions posed in an Editorial from March
25, 2006 entitled, “Acupressure for low back pain: promising but not
proved” by Helen Frost and Sarah Stewart-Brown. Although a healthy
amount of skepticism encourages claimants to produce even more conclusive
evidence to support their positions, I feel many of the questions posed
are naïve, from someone who has very little understanding of oriental
medicine and the Orient in general.
Frost questions the validity of the results by suggesting that if the
success rate was as high and Hsieh purports, then why aren’t more Chinese
medicine clinicians using acupressure over acupuncture? I feel there is a
simple sociological explanation for this – as I am sure we can all agree,
individuals are frequently reluctant to engage in change.
It is quite possible that there are many clinicians practicing acupressure
successfully – although most of which do not possess the knowledge or
ability, or feel compelled to conduct randomized clinical trials such as
Hsieh.
Frost also questions the validation of patients using the English
language to describe their outcomes after treatment. Hsieh explained in
detail the data compiled from her trial during my treatments and I found
that these surveys were conducted in Mandarin (the main language in
Taiwan); and then translated by one group of professional translators from
Mandarin to English to ensure consistency. I assume Frost is insinuating
that the Taiwanese patients and those conducting the trials lack the
ability to properly understand and/or translate the surveys provided?
What about the cost effectiveness of acupressure over physical
therapy? Physical therapy in the United States is entangled in our less
than efficient healthcare system. And I have received physical therapy in
the price range of $50-$150 USD per treatment for an average of three
times a week for six weeks. The acupressure as mentioned in the study
only requires six sessions (such sessions would have a general price range
of $30 USD per treatment, although the study was conducted at no charge)
for a period of one month.
We had no expectations, just some general skepticism, when we entered
into this treatment with Hsieh because we have used Western medicine
(sometimes supplemented with acupuncture) with little success. We are
only pleasantly surprised and relieved by the amount of pain alleviated
after treatment. My wife and I both agree that we are some of the
fortunate few whom have received the specific acupressure treatment
referenced by Hsieh. This limitation is largely due to logistics – as the
senior therapist and orthopedic clinic both have a domicile in Kaohsiung,
Taiwan. However, the fact that few residents in the United States and/or
Europe have benefited from these treatments does not invalidate or
diminish the tremendous success of this form of acupressure.
We do, however, agree with one point raised by Frost; that is, we
need to know and locate those practitioners (Chinese or otherwise) who can
achieve this level of success by acupressure. However, we strongly feel
that Hsieh’s treatments are amplified because of her unique ability to
provide a medical diagnosis and prognosis to the symptoms identified
during her acupressure treatments – which should be fostered and
encouraged by the medical community. We would ask that your community,
rather than publish editorials which raise questions substantiated by
little research and understanding for the oriental culture, encourage
therapists such as Hsieh to effectively train practitioners so that we can
have more researchers, therapists, publications, etc…in support of this
highly effective means of alleviating physical pain and illness.
Very Truly Yours,
Mr. Randolph J Wagner, MBA, PMP
Mrs. Jean Wagner, JD
12301 Falls Road
Potomac, MD 20854
Competing interests:
None declared
Competing interests: No competing interests
I notice that the PT intervention is described as follows:
"The participants in the physical therapy group received the routine
physical therapy offered by the orthopaedic specialist clinic, including
pelvic manual traction, spinal manipulation, thermotherapy, infrared light
therapy, electrical stimulation, and exercise therapy, as decided by the
physical therapist."
This is problematic siimply because the study variable becomes the
individual therapist and treatment choice rather than any specific
modality. The therapist could have chosen simply electrical stimulation,
which in most cases would be less than the standard of care. I understand
the difficulty in creating a method to study outcomes by using only one
treatment, but the conclusions drawn certainly do not consider that the
outcomes are more related to the therapist and the therapist treatment
choices than "physical therapy" in general.
Competing interests:
None declared
Competing interests: No competing interests
Dear Dr. White,
Thank you for your further enquiry. It is a pity that you
misunderstand the background about the enrollment of study subjects in our
study. Your question arise form your imaginative scenario rather than
ours. The characteristics and enrollment process of our study subjects are
not like your description. The following is my reply.
1. (Q) "Am I correct in that your design involved a cohort... with
chronic pain?"
(A) Incorrect. I think you imagine the enrollment of study subjects
in our study as cohort membership in the same clinics/hospital as perhaps
seen in your private medical system. In our health care system, patients
are free to visit any clinical/hospital for treatment. Patients may see
different clinics/hospitals due to different episodes. It is therefore
very difficult to enroll a cohort of subject with chronic LBP and that
cohort had a previous trial of physical therapy in the same clinics before
study. Study subjects selected into our study attended our study hospital
at their discretion. Your description on our disproportional selection of
failure therapy through repeated visits in the same cohort is therefore
not correct. When you wrote e-mail to ask me about the question of
"satisfaction with care" in Table 3, which actually is an optional
question in core set developed by Deyo et al rather than our own developed
question (see Deyo 1998 Spine) we gave you a reply with physical therapy
because the mainstay treatment for LBP in most orthopaedic clinics in
Taiwan is physical therapy. This does not mean they received physical
therapy in the same hospital/clinic like a cohort. One may be concerned
about selection bias caused by previous treatment history. To do objective
evaluation, we therefore applied a randomized controlled trial, which has
been regarded as the best method to avoid the selection bias (Roberts and
Torgerson, BMJ, 1998).
2. (Q) "Is it also correct that the previous trial of PT did not
resolve .......further treatment and were subsequently enrolled in your
study"
(A) Incorrect. I have already answered this question in earlier
response. Following the answer in question 1, the second argument is
evidently not correct. From clinical viewpoint, this point even for the
enrollment of subjects with the same cohort is also not adequate. For
patients with chronic LBP it is frequently for them to have new episode or
recurrence of LBP, prompting them to visit clinic. Note that chronic LBP
is a recurrent chronic disease. Cure for patients with current episode
does not guarantee no episode at all afterward. How does one define
"success" or "failure"? Please read the rapid response in the
accompanying series, a patient who has already 11 years of chronic LBP and
she describe physical therapy help her. If you define this case as failure
then the real reason according to her description is nothing to do with
physical therapy but the aspect of depression due to pain. That's why our
study subjects were targeted at chronic LBP more than four months because
this group constitute of the majority of LBP in need of effective
treatment.
Reference:
Roberts C, Torgerson D. Understanding controlled trials. Randomisation
methods in controlled trials. BMJ 1998; 317:1301.
Competing interests:
None declared
Competing interests: No competing interests
Professor Chen:
Thank you for your response. I would be appreciative if you could clarify the methodology used in the study. Am I correct in that your design involved a cohort of subjects with chronic low back pain and that cohort had a previous trial of physical therapy (PT) prior to the study? Is it also correct that the previous trial of PT did not resolve their low back pain which is why they presented to the clinic for further treatment and were subsequently enrolled in your study?
If this is correct then I would offer the following comments:
To repeat PT for one cohort who had already a course of PT is at least a confounding variable. There is also the element of a Hawthorne effect. Repeating a treatment that has already been shown not to be beneficial is a major limitation to any study. It is logical to presume that if the first course of PT had been successful then the study participants would not have sought further treatment at the clinic where they were subsequently enrolled in the study. If the first course of PT was unsuccessful then the likelihood of a second course of PT being successful is remote.
To accurately compare PT and acupressure for individuals with chronic low back pain then the cohorts should not have prior experience with the two variables. That is not to say they cannot have had some other type of treatment such as medication or home exercise. If the study methodology is as I have described above then the study is biased in favor of acupressure and the discussion and conclusion should appropriately reflect this limitation in study design.
The specific PT interventions described in the study appear to have been individualized and decided by the physical therapist. There does not appear to be standardization of PT interventions across the cohort. Thus generalized statements as to the effectiveness of PT cannot be made nor can generalized statements as to the effectiveness of acupressure as compared to PT for individuals with chronic low back pain be made unless the PT is standardized. As noted by another respondent acupressure is a PT intervention. Given the variability of the PT interventions it would not be possible to replicate the study.
Competing interests:
None declared
Competing interests: No competing interests
Dear Dr Walker,
Thank you for your comments on heterogeneity of clinical skills and
treatment techniques related to low back pain across countries and your
proposal for a perspective research area on the combined treatment with
physical therapy and acupuncture/acupressure.
Your point on heterogeneity of treatment modalities for chronic low
back pain (LBP) is very realistic. As a matter of fact, such variation may
be observed not only across countries but also between different
institutions in the same country. This point is exactly one of our
motivations to do randomized trials for testing the efficacy of
acupressure given variation as a result of different therapists and
different characteristics of patients. This point has a significant
clinical implication for the application of Western medicine /alternative
medicine to LBP in countries where Western medicine and alternative
medicine such as acupuncture and acupressure are potentially intermingled.
Different cultures in different areas may lead to heterogeneous clinical
skills and treatments. In Asian countries like Taiwan, I think in addition
to conventional physical therapy, alternative medicine such as
acupuncture/acupressure is popular and accepted by folk people. Some
Taiwanese people or physicians specialized in Chinese/alternative medicine
have deep-rooted belief or a liking for seeking or using alternative
medicine only and do not want take regular conventional therapy. The
extreme case can be found in patients who had been diagnosed as liver
cancer but only sought alternative medicine such as herbal medicine or
mixed with Western medication. Similar situations were seen in chronic LBP
treated with physical therapy or alternative medicine
(acupuncture/acupressure) or both. As seen in China (Hesketh et al, BMJ
1997;315:115-117), there are two separate medical systems in Taiwan as
well: Western medication and Chinese medication. The recent payment system
of national health insurance was also distinct for two separate medical
systems. In the past, it may not be practiced in orthopaedic specialist
but in other settings characterized with alternative medicine. However, it
has increasingly gained attention and has been gradually incorporated to
become part of a single and independent entity in orthopaedic clinics in
our health care system. Any medical practitioner is not allowed to
practice both and only one can be chosen. However, technique skill and
clinical treatment for LBP in our country is still fraught with variation
and has been barely proved by evidence-based principle, particularly with
randomized controlled trial. As different cultures and health beliefs may
lead to different scenarios for the study, the comparison with randomized
controlled design between acupressure and physical therapy. However, I
think this design may be unnecessary for the country where physical
therapy has become the mainstay and indispensable.
The viewpoint of combined therapy may also have a significant
implication for the evolution of treatment pattern for LBP in different
countries. Our emphasis on this article is by no means intended to replace
or look down upon physical therapy, the mainstay for treating physical
therapy and already known as an effective method for relieving LBP pain,
or to suggest using acupressure exclusively. Instead, we give acupressure
a challenge using a randomized trial. Following evidence-based principle
and considering the ethical viewpoint, we have no choice but select the
group receiving conventional physical therapy group as the comparison
group because it is unethical to take people without treatment as the
control group. Although our article concluded acupressure is more
effective but it does not mean the same results would be anticipated if a
similar trial is conducted in other places or therapists because the
outcome still depends on the technique skill and variation of patients. As
pointed out in our discussion, the use of a single therapist in our study
may reduce internal validity but external application is still very
limited. Whether acupressure can be standardized and performed well still
varies from place to place. Since physical therapy has been demonstrated
to be effective and is the mainstay treatment for LBP in the country such
as USA and UK. There is no reason to dispense with this conventional
therapy in countries where the majority of people has been accustomed to
Orthodox medicine. Instead, the comparison between combined therapy and
physical therapy as suggested should be addressed. To the great delight,
the developed country like UK has already incorporated alternative
medicine as adjunct therapy. From the patient perspective, we do hope
Chinese people or providers who were impregnated with alternative medicine
can also embrace effective Western medicine in the future in order to
relieve pain from patients. After all, different therapies have their own
merits. It is like coins used with different styles in different countries
but having one character in common i.e."Head" and "Tail",
corresponding to Western medicine and Chinese medicine, respectively. We
have to own both sides of coin instead of only one side if it is useful
for commercial interest. Doing so may really render patients receive more
benefit compared with single and separate therapy. However, different
cultures, beliefs, and health care systems may make things complicated and
hard to reach consensus. We are therefore looking forward to seeing the
perspective of maximizing the benefit for patients given the combined
therapy covering conventional physical therapy, acupuncture/acupressure,
cognitive re-structuring and bio-feed back, massage and other possible
effective modalities. However, the optimal modalities may vary from
country to country and need to have evidence-based data to support given
the variability of different treatment modalities in different countries.
Given scarce resources and increased demand for treatment, economic
evaluation including quality of life of patients with LBP may also be
required.
Tony Hsiu-Hsi Chen
Ref:
1) Hesketh T, Zhu WX. Health in China. Traditional Chinese medicine: one
country, two systems. BMJ 315:115-7,1997.
Competing interests:
None declared
Competing interests: No competing interests
The study and responses raise valid points. As a long term back pain
patient, I continue to search for relief from pain. Over the last 11
years, I have repeatedly turned to physical therapists and Bio-feedback
techniques for help rather than just take more medicines. In every case
these techniques helped with varying degrees of relief retention.
The skill and background of the therapist has a great deal to do with the
results - some see repeated returns as a waste of their time whereas
others are more comitted to helping. The ultimate problem is that
continuing pain is poorly understood by all concerned and the inability to
maintain sufferable levels does indeed effect the state of mind. I believe
that once you and your medical team reach some level of trust-
understanding, that the depressing aspects lessen.
Another reason for depression is the never ending requirement (at
least in the U.S) to get new prescriptions monthly as refills are not
allowed by law. This ties us down and imposes sometimes difficult
restrictions that add to the problem. In the end I schedule my future
around the rx cycle.
Competing interests:
None declared
Competing interests: No competing interests
Dear Professor Hsiu-Hsi Chen,
Thankyou for a thought provoking article. It is interesting to
address the clinical skills and treatment techinques employed by
physiotherapists/physical therapists in different countries.
In the United Kingdom and several other countries, many physical
therapists take postgraduate courses in acupuncture (including:
traditional, acupressure, laser acupuncture, electo-acupuncture)
accredited by a special interest group of the chartered society of
physiotherapy (AACP, 2006)
Do the physical therapists from your orthopaedic specialist clinic in
Taiwan usually employ acupressure/acupuncture in their clinical caseload?
If they do not practice acupuncture/acupressure, i would question how
easily this study could be replicated in the UK, as acupressure may well
be a treatment tool that a UK physiotherapist would use in the treatment
of back pain.
I believe that acupuncture is an extremely useful treatment
technique, but it should not be used exclusively of other
physiotherapeutic techniques. Acupressure/Acupuncture as employed by
physiotherapists in combination with other traditional techniques can be
more powerful than either would be independently. This would certainly be
an interesting further area for research, but would be country specific.
I await your comments with interest.
Many Thanks,
Andrew Walker BSc (Hons) MCSP
Ref:
1)AACP (2006) Accupuncture association of Chartered Phsyiotherapists.
<http://www.aacp.uk.com/>
Competing interests:
None declared
Competing interests: No competing interests
Use of Cognitive re-structuring and Bio-feed back procedures for back
pain.
Cognitive Re-structuring:
Our thoughts can have a profound effect on our mood and physical state-
including our perception of physical pain.
If you constantly tell yourself, "I don't see how this pain is ever going
to get better," or "I can't take it anymore," as many pain patients do,
you may exacerbate your pain in three ways.
1. It becomes hard to develop the sense of power and control necessary to
fight the pain.
2. These self-defeating, stressful thoughts can further tense your
muscles.
3. Such thoughts may alert the nervous system to widen the pain gate and
increase the discomfort.
Cognitive restructuring revises the way you think about your problem by
rewriting your internal "script." It has been successful in treating a
number of psychological problems, most notably depression. In the
treatment of chronic pain, cognitive restructuring is used as an adjunct
to other approaches, such as relaxation.
Bio-feed back procedures:
Biofeedback procedures are also useful in managing back pain. The
technique known as electromyographic (EMG) biofeedback alerts you to know
thelectrical activity from muscle tension, thus helping you control it and
diminish the pain it causes
Competing interests:
None declared
Competing interests: No competing interests
Acupressure also effective in dysmenorrhea, pelvic pain and labour pain.
Dear Editor,
I believe that mister Jay Defigh and mister Eric Allen made comments
on this trial's design which are not practical or even applicable.
Not in this or any other research project!
Certified, experienced, physical therapists in a specialized
orthopaedic clinic took care of patients assigned to the control group.
This is good enough for me.
Should we suggest that:
1) They only used one type of physical therapy?
2) They only applied it at certain parts of the body?
3) They only used devices of a certain brand?
4) They only used lubricating ointments of a certain brand?
5) They only applied it for exactly 40 minutes at each session?
6) They only applied 20 sessions to each patient regardless of
clinical response?
7) They only applied their physical therapy sessions in the morning,
starting exactly at 08:45?
8) They only enrolled patients of exactly the same age, body mass
index, smoking habits, alcohol consumption, type of profession, NSAID use,
osteoporosis score?
Etc
This list could go on forever, but I do not think all these excessive
and impractical limitations would alter the fact that acupressure was
proven more effective than physical therapy in reducing low back pain in
terms of disability, pain scores and functional status, with sustained
benefit even after 6 months!
Acupressure has also been proven very effective in treating
dysmenorrhea, chronic or acute, pelvic pain, chronic or acute, and even
labour pain. [1] [2] [3] [4] [5] [6] [7] [8] [9] [10] [11] [12] [13] [14]
I would like to ask the Authors of this study if they could be kind
enough to specify the exact acupressure points used, and if they believe
that these could also be used for treating obstetric pain, together with
the more specific LI4, SP6, ST36, and LIV3 ones.
Thank you in advance.
[1]Complement Ther Clin Pract. 2011 Feb;17(1):33-6. Epub 2010 Jul 10.
The effects of acupressure on primary dysmenorrhea: a randomized
controlled trial.
Mirbagher-Ajorpaz N, Adib-Hajbaghery M, Mosaebi F.
[2]Complement Ther Clin Pract. 2010 Nov;16(4):198-202. Epub 2010 May
20.
Effect of acupressure at the Sanyinjiao point on primary dysmenorrhea: a
randomized controlled trial.
Kashefi F, Ziyadlou S, Khajehei M, Ashraf AR, Fadaee AR, Jafari P.
[3]Int J Gynaecol Obstet. 2010 Nov;111(2):105-9. Epub 2010 Jun 12.
A randomized clinical trial of the efficacy of applying a simple
acupressure protocol to the Taichong point in relieving dysmenorrhea.
Bazarganipour F, Lamyian M, Heshmat R, Abadi MA, Taghavi A.
[4]Complement Ther Clin Pract. 2010 May;16(2):64-9. Epub 2009 Nov 14.
Effects of SP6 acupressure on pain and menstrual distress in young women
with dysmenorrhea.
Wong CL, Lai KY, Tse HM.
[5]J Manipulative Physiol Ther. 2010 Jan;33(1):70-5.
Successful treatment of primary dysmenorrhea by collateral meridian
acupressure therapy.
Lin JA, Wong CS, Lee MS, Ko SC, Chan SM, Chen JJ, Chen TL.
[6]Int J Nurs Stud. 2007 Aug;44(6):973-81. Epub 2006 Jun 16.
Effects of acupressure on dysmenorrhea and skin temperature changes in
college students: a non-randomized controlled trial.
Jun EM, Chang S, Kang DH, Kim S.
[7]J Tradit Chin Med. 2002 Sep;22(3):205-10.
Effects of acupressure and ibuprofen on the severity of primary
dysmenorrhea.
Pouresmail Z, Ibrahimzadeh R.
[8]J Altern Complement Med. 2002 Jun;8(3):357-70.
A randomized clinical trial of the effectiveness of an acupressure device
(relief brief) for managing symptoms of dysmenorrhea.
Taylor D, Miaskowski C, Kohn J.
[9]J Reprod Med. 2000 Nov;45(11):944-6.
Use of acupuncture for managing chronic pelvic pain in pregnancy. A case
report.
Thomas CT, Napolitano PG.
[10]J Matern Fetal Neonatal Med. 2009 Sep 15:1-4.
Effects of acupressure at the Sanyinjiao point (SP6) on the process of
active phase of labor in nulliparas women.
Kashanian M, Shahali S.
[11]Kaohsiung J Med Sci. 2005 Aug;21(8):341-50.
Effect of acupressure on nausea, vomiting, anxiety and pain among post-
cesarean section women in Taiwan.
Chen HM, Chang FY, Hsu CT.
[12]J Altern Complement Med. 2004 Dec;10(6):959-65.
Effects of SP6 acupressure on labor pain and length of delivery time in
women during labor.
Lee MK, Chang SB, Kang DH.
[13]Drugs Today (Barc). 1998 Jun;34(6):525-36.
Epidural and other labor analgesic methods.
Thorp JA, Murphy-Dellos L.
[14]Cochrane Database Syst Rev. 2006 Oct 18;(4):CD003521.
Complementary and alternative therapies for pain management in labour.
Smith CA, Collins CT, Cyna AM, Crowther CA.
Competing interests: No competing interests