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Self-Rated
Pain And Functional
Status With Acupuncture
Thiru M. Annaswamy,
MD
Paul E. Satwicz, MD
Joanne Borg-Stein, MD
Elizabeth Eisenhardt
ABSTRACT
Background Acupuncture has been widely used for the management
of musculoskeletal pain, but relatively little information is available
regarding its effect on functionality.
Objectives To determine if acupuncture is effective for
the management of pain, and to determine if it provides benefits to
patients' functionality.
Design Retrospective chart review and follow-up telephone
survey.
Setting and Patients A total of 135 consecutive patients
seen in outpatient physical medicine, rehabilitation, and pain management
clinics for low back pain/radiculopathy, myofascial pain syndromes,
fibromyalgia, and other conditions. Follow-up data were available via
telephone for 64 patients.
Interventions All patients received acupuncture for pain
relief.
Main Outcome Measures Perceived pain on a 10-cm visual
analog scale, functional status using a 10-point activity scale, and
work status. Overall global improvement was measured using self-assessed
"percentage improvement."
Results The mean (SD) duration of pain prior to acupuncture
was 75 (107) months. The mean number of acupuncture treatments was 5
(range, 1-13). At the conclusion of treatment, the mean (SD) self-rated
percentage improvement was 53% (34%). Pain scores decreased from a mean
(SD) of 6.6 (2.0) to 4.76 (2.54) (P<.01). Activity scores also showed
significant improvement, from a mean (SD) of 6.61 (2.72) to 7.04 (2.70)
(P<.05). Patients with long-term follow-up reported the following:
overall improvement (mean, 38%), pain scores (mean, 5.52), and activity
scores (mean, 6.81). These did not change significantly compared with
their respective short-term outcome measurements.
Conclusions Acupuncture appears to provide sustained pain
relief and functional improvement in patients with a variety of pain
syndromes, both acute and chronic.
KEY WORDS
Acupuncture, Chronic Pain, Function, Alternative Medicine, Low Back
Pain, Rehabilitation
INTRODUCTION
The use of different forms of complementary medicine, including acupuncture,
has been reported to be widespread in the United States, with as much
as 30%-34% of the population using some form of complementary/alternative
medicine each year.1,2 While the popularity of such modalities continues
to increase, there have been few published reports of scientific studies
documenting the benefits that such techniques may provide.
Acupuncture is commonly used in clinical practice as a complementary
therapeutic technique for a variety of acute and chronic pain syndromes.
Improvement in pain after acupuncture has been reported in a number
of studies,3-7 although other studies8 have not supported this conclusion.
Some researchers have found that longstanding or chronic pain responds
poorly to acupuncture.5 Results of meta-analyses have been inconclusive
about the benefits of acupuncture or the role that acupuncture plays
in the treatment of chronic pain disorders.9,10 A National Institutes
of Health consensus statement suggested, but could not unequivocally
state, that acupuncture is beneficial for specific types of pain disorders.11
Individuals with chronic pain disorders generally have reduced levels
of activity or functioning ability. A holistic approach to such patients
should include interventions or treatment approaches aimed at not only
alleviating their pain, but also improving their overall function and
level of activity. Acupuncture has been purported to be a holistic therapeutic
approach that regulates and improves general well-being, thereby improving
overall functioning in addition to the specific purpose for which it
is used. Since acupuncture has generally been used in the United States
as a technique to treat pain, research in acupuncture has traditionally
focused mainly on various measures and scales of pain as outcomes. In
addition, most of the published reports have analyzed only immediate
or short-term changes in pain scores. Few acupuncture studies, if any,
have reported on functional outcome measures or long-term follow-up
data.
We performed a retrospective chart review and a follow-up telephone
survey of patients who underwent acupuncture treatment for chronic pain
conditions. We studied self-rated pain and functional outcomes on completion
of treatment and at follow-up. This study is perhaps the first to look
at short-term and long-term functional outcomes of chronic pain patients
who underwent acupuncture treatment.
METHODS
Patients were seen in an outpatient rehabilitation or pain clinic for
a variety of complaints. Data from 135 consecutive patients who received
acupuncture as a treatment option for their chronic pain were retrospectively
reviewed. Patients were included if they had completed all their acupuncture
treatments at least 2 weeks before study onset. Acupuncture was administered
by 2 certified physician acupuncturists. Acupuncture techniques included
auricular, French Energetics, and 2 neuroanatomic techniques, often
with electrical stimulation. The choice of acupuncture technique was
based on patient diagnoses. Duration of each acupuncture treatment was
approximately 30 minutes.
Patients reported self-rated scores on the following outcome measures
after each acupuncture session: (1) perceived level of pain on a 10-cm
visual analog scale, (2) functional status using a 10-point activity
scale, and (3) global overall improvement measured as a "percentage
improvement" since the first acupuncture session. The activity
and global improvement scales were based on similar scales developed
in various clinics throughout the country (unpublished data). Data from
the first and last acupuncture sessions were used for the "initial"
and "final" scores, respectively. A telephone follow-up survey
was conducted at a later date to obtain long-term data on the above
outcome measures. Data from the outcome measures were then analyzed
at 2 points in time: immediately on completion of treatment, and from
the follow-up survey. Non-responders were defined as persons who demonstrated
no greater than 0% overall global improvement immediately on completion
of treatment. The outcome measures were statistically analyzed in the
entire group and the responder group separately, in part to identify
any differences in the non-responder group.
Statistical analyses included descriptive statistics and paired t tests.
Patients were sub-grouped based on duration of symptoms prior to acupuncture
and also, major diagnostic categories to study associations and trends
with outcome measures. The major diagnostic categories were (1) myofascial
pain, fatigue syndromes, and fibromyalgia syndrome, (2) back pain with
or without radicular complaints, and (3) other diagnoses.
RESULTS
Of the 135 patients, 103 (76%) were women. The mean (SD) age was 48
(14) years (range, 25-87 years). The mean (SD) duration of symptoms
before the first acupuncture session was 75 (107) months (range, 3 days
to 50 years). Reported duration of symptoms as "several years"
or "many years" was confirmed with the patient if it was more
than 10 years, and then was entered as 120 months. The median number
of acupuncture treatments received was 5 (range, 1-13 sessions).
Telephone follow-up (n=64) was conducted a mean (SD) of 7 (4)
months after the last acupuncture session (range, 0.5-16 months); 15
patients completed the follow-up interview within 3 months, and 3 patients
were interviewed within 1 month of treatment.
Mean global improvement with acupuncture, recorded immediately after
the final acupuncture treatment, was 53% (SD, 34%); 22 patients (16%)
were non-responders. Mean global improvement among responders was 61%
(SD, 28%).
Paired t tests revealed statistically significant short-term improvements
in pain and activity scores. Final pain score (mean [SD], 4.76 [2.54])
was significantly improved compared with the initial pain score (mean
[SD], 6.6 [2.0]) (P<.01); final activity score (mean [SD], 7.04 [2.70])
was significantly improved compared with the initial activity score
(mean [SD], 6.61 [2.72]) (P<.05).
Among patients with long-term follow-up data, there was a trend
suggesting sustained improvement in pain and activity scores. Mean pain
scores changed from an initial score of 6.58 (SD, 1.61) to a final score
of 5.16 (SD, 2.37), and to a follow-up score of 5.52 (SD, 2.54) (P<.01).
Mean activity scores changed from an initial score of 6.35 (SD, 2.76)
to a final score of 6.6 (SD, 2.7), and to a follow-up score of 6.81
(SD, 2.56) (P=.10). Among patients with long-term follow-up data, mean
global improvement scores changed from 47% (SD, 31%) to 38% (SD, 38%)
[P=.52].
Worse pain scores short-term (P<.01) were reported by 11 patients,
among whom 3 patients eventually reported long-term improvement. On
the global overall improvement scale, 3 were non-responders and 8 reported
15% to 70% global improvement.
Sub-grouping according to diagnostic categories revealed statistically
significant short-term improvements in pain (P<.01) and activity
scores (P<.05) in all subgroups except in the back pain group, which
showed only a trend toward improvement in pain
scores (Figure 1). Mean short-term global improvement scores were
45% (SD, 34%) in the myofascial pain, fatigue syndromes, and fibromyalgia
syndrome group, 47% (SD, 36%) in the back pain group, and 52% (SD, 33%)
in the other diagnoses group.
Sub-grouping according to duration of symptoms revealed significant
short-term improvements in pain scores only in the 2 most acute and
2 most chronic groups (Figure 2). Mean short-term global improvement
scores in each duration of symptoms sub-group
are shown (Figure 3).
DISCUSSION
Statistically and clinically significant improvement was noted in all
outcome measures immediately following completion of treatment, indicating
good short-term benefits. The short-term improvements in pain and activity
scores were clinically relevant because many of these patients had pain
complaints and activity limitations for several years before acupuncture,
and had minimal response to conventional treatment
strategies. A total of 113 patients (84%) were responders, demonstrating
at least 61% short-term global improvement with acupuncture. This response
rate compares favorably to that in previously published studies.12 To
our knowledge, this is the first published report on acupuncture to
examine both pain and functional outcome measures.
Improvement in outcome measures was generally sustained at follow-up,
although outcomes exhibited a tendency to gradually regress toward initial
scores. We did not perform sub-group analyses on follow-up data because
of lack of statistical power. However, if such an analysis could identify
sub-groups of patients whose outcomes tended to regress toward initial
scores, those sub-groups might benefit from follow-up acupuncture treatments
on a more regular basis to help maintain sustained improvement.
Sub-grouping according to broad diagnostic categories did not reveal
a trend or association, suggesting that benefits in outcome were not
related to specific diagnostic categories in this population. Stricter,
pre-defined, well-documented diagnostic categories along with a much
larger sample size could aid in identifying some populations who might
especially benefit from acupuncture.
Sub-grouping according to duration of symptoms revealed significant
short-term benefits in pain scores at both ends of the spectrum, although
no other trends or associations were identified. However, the most "acute"
sub-group in our study consisted of patients with duration of symptoms
between 0 and 5 months, which included patients (duration of symptoms
>3 months) who might have been classified as having chronic pain
in other studies. The relatively broad range of symptom duration is
a limitation of this study, and the sample size does not permit meaningful
evaluation of sub-groups. On the other hand, improvements in the chronic
end of the spectrum are especially significant because patients with
chronic pain have historically been the most challenging group to treat.12
This study was a retrospective chart review and thus was not blinded.
Patients received other treatments concurrent with acupuncture which
was not controlled in our analyses. There were also no control or sham
groups; therefore, neither placebo effect nor the natural course of
pain recovery over time could be assessed. Large-scale and prospective,
controlled, randomized studies need to be performed to assess the role
of acupuncture in providing relief and functional benefits to patients
with painful musculoskeletal disorders. We are conducting a follow-up
study with more detailed assessment of functional outcome in patients
with disorders including low back pain, neck pain, and fibromyalgia
syndrome.
CONCLUSION
Acupuncture appears to provide both short-term and long-term pain relief
and functional improvement in patients with a variety of painful musculoskeletal
disorders.
REFERENCES
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2. Wainapel SF, Thomas AD, Kahan BS. Use of alternative therapies by
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3. Cheung JY. Effect of electro-acupuncture on chronic painful conditions
in general medical practice: a 4 years' study. Am J Chin Med. 1985;13:33-38.
4. Junnila SY. Long-term treatment of chronic pain with acupuncture,
part I. Acupunct Electrother Res. 1987;12:23-36.
5. Junnila SY. Long-term treatment of chronic pain with acupuncture,
part II. Acupunct Electrother Res. 1987;12:125-138.
6. Birch S, Hammerschlag R, Berman BM. Acupuncture in the treatment
of pain. J Altern Complement Med. 1996;2:101-124.
7. Peng AT, Behar S, Yue SJ. Long-term therapeutic effects of electro-acupuncture
for chronic neck and shoulder pain: a double blind study. Acupunct Electrother
Res. 1987;12:37-44.
8. Petrie JP, Hazleman BL. A controlled study of acupuncture in neck
pain. Br J Rheumatol. 1986;25:271-275.
9. Patel M, Gutzwiller F, Paccaud F, Marazzi A. A meta-analysis of acupuncture
for chronic pain. Int J Epidemiol. 1989;18:900-906.
10. ter Riet G, Kleijnen J, Knipschild P. Acupuncture and chronic pain:
a criteria-based meta-analysis. J Clin Epidemiol. 1990;43:1191-1199.
11. Trachtenberg AI. American Acupuncture: Primary Care, Public Health
and Policy. Bethesda, Md: National Institutes of Health; 1997:137-138.
12. Pomeranz B. Summary of Acupuncture and Pain. Bethesda, Md: National
Institutes of Health; 1997:87-90.
(Note: Presented in part as a poster at the 60th annual assembly of
the American Academy of Physical Medicine and Rehabilitation, Seattle,
Washington, 1998.)
AUTHORS'
INFORMATION
Dr Thiru Annaswamy is a full-time faculty member in the Department of
Physical Medicine and Rehabilitation at University of Texas Southwestern
Medical School, Dallas, Texas. His clinical practice is primarily in
the areas of spine and musculoskeletal care, and electrodiagnosis. Dr
Annaswamy's special interest is Gait Analysis and related areas, and
he also works on the applications of Haptics and Virtual Reality technology
to clinical and research problems in Physical Medicine and Rehabilitation.
Thiru M. Annaswamy, MD, MA*
Department of Physical Medicine & Rehabilitation
The University of Texas Southwestern Medical Center at Dallas
5323 Harry Hines Blvd
Dallas, TX 75390-9055
Phone: 214-648-2288 o Fax: 214-648-8828
E-mail: thiru.annaswamy@utsouthwestern.edu
Dr Joanne Borg-Stein is on the faculty of Harvard Medical School, Department
of Physical Medicine and Rehabilitation, Boston, Massachusetts; Medical
Director of the Spaulding-Wellesley Rehabilitation Center, Wellesley,
Massachusetts; and Chief of Physical Medicine and Rehabilitation at
Newton-Wellesley Hospital, Newton, Massachusetts.
Joanne Borg-Stein, MD
Spaulding-Wellesley Rehabilitation Center
65 Walnut Street
Wellesley, MA 02481
Phone: 781-431-9144 o Fax: 781-431-9152
E-mail: jborgstein@partners.org
Dr Paul Satwicz is an Anesthesiologist and Pain Specialist, and is the
Director of the Pain Clinic at Newton Wellesley Hospital in Newton,
Massachusetts. Dr Satwicz has incorporated Medical Acupuncture in a
variety of wilderness medical settings and sports-related injuries.
Paul E. Satwicz, MD
2014 Washington Street
Newton, MA 02462
Phone: 617-243-6142
Ms Elisabeth Eisenhardt is a Medical Assistant at Harvard Vanguard Medical
Associates, Boston, Massachusetts. She will soon be entering medical
school.
Elizabeth Eisenhardt, BA
78 Stedman Street, #3
Brookline, MA 02446
Phone: 617-654-7221
E-mail: eeisenhardt@yahoo.com
*Address all correspondence to: Dr Thiru M. Annaswamy, Dept of Physical
Medicine and Rehabilitation, University of Texas Southwestern Medical
Center, 5323 Harry Hines Blvd, Dallas, TX 75390-9055. Phone: 214-648-2288;
Fax: 214-648-8828; E-mail: thiru.annaswamy@utsouthwestern.edu.
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