[好書] New England Journal of Medicine(2010;363:454-461)

[strongshort (力量與智慧)]

對於某些還在爭辯科學的無聊話題
那就來篇最有重量性的科學文章好了

Acupuncture for Chronic Low Back Pain

Brian M. Berman, M.D., Helene H. Langevin, M.D., Claudia M. Witt, M.D.,
M.B.A. and Ronald Dubner, D.D.S., Ph.D.

N Engl J Med 2010; 363:454-461July 29, 2010

僅摘錄片段:

Acupuncture is a therapeutic intervention characterized by the insertion of
fine, solid metallic needles into or through the skin at specific sites.29,30
 The technique is believed to have originated in China, where it has remained
a fundamental component of a system of medical theory and practice that is
often termed “traditional Chinese medicine.” Although a number of different
techniques or schools of acupuncture practice have arisen, the approach used
in traditional Chinese medicine appears to be the most widely practiced in
the United States.31

Traditional Chinese medicine espouses an ancient physiological system (not
based on Western scientific empiricism) in which health is seen as the result
of harmony among bodily functions and between body and nature. Internal
disharmony is believed to cause blockage of the body's vital energy, known as
qi, which flows along 12 primary and 8 secondary meridians (Figure 1Figure
1Acupuncture Meridians.). Blockage of qi is thought to be manifested as
tenderness on palpation. The insertion of acupuncture needles at specific
points along the meridians is supposed to restore the proper flow of qi.

Efforts have been made to characterize the effects of acupuncture in terms of
the established principles of medical physiology on which Western medicine is
based. These efforts remain inconclusive, for several reasons. First, the
majority of studies have been conducted in animals, and it is difficult to
relate findings from such studies to effects in humans. Second, acupuncture
has been shown to activate peripheral-nerve fibers of all sizes, rendering a
systematic study of responses complex. Third, the acupuncture experience is
dominated by a strong psychosocial context, including expectations, beliefs,
and the therapeutic milieu.32-34

Despite these limitations, some physiological phenomena associated with
acupuncture have been identified. Local anesthesia at needle-insertion sites
completely blocks the immediate analgesic effects of acupuncture, indicating
that these effects are dependent on neural innervation.35 Acupuncture has
been shown to induce the release of endogenous opioids in brain-stem,
subcortical, and limbic structures. 36,37 In the rat, electroacupuncture has
been shown to induce pituitary secretion of adrenocorticotropic hormone and
cortisol, leading to systemic antiinflammatory effects.38 Functional MRI
studies in humans have shown immediate effects of prolonged acupuncture
stimulation in limbic and basal forebrain areas related to somatosensory and
affective functions that are known to be involved in pain processing.39
Results on positron-emission tomography have shown that acupuncture increases
μ-opioid–binding potential for several days in some of the same brain
areas.40 Acupuncture also has effects on local tissues, including mechanical
stimulation of connective tissue,41 release of adenosine at the site of
needle stimulation,42 and increases in local blood flow. 43 However, the
various observations that have been made are not sufficient to permit a
unified theory regarding the effect of acupuncture on mechanisms of chronic
pain.

以下提到一些臨床EBM

A number of clinical trials have evaluated the efficacy of acupuncture for
chronic low back pain. A meta-analysis in 2008, which involved a total of
6359 patients,44  showed that real acupuncture treatments were no more
effective than sham acupuncture treatments. There was nevertheless evidence
that both real acupuncture and sham acupuncture were more effective than no
treatment and that acupuncture can be a useful supplement to other forms of
conventional therapy for low back pain. These conclusions were supported by a
subsequent meta-analysis from the Cochrane Back Review Group.45 Details of
several of the major recent clinical trials that were included in these
meta-analyses are provided in the Supplementary Appendix, available with the
full text of this article at NEJM.org.46-50

In a large German study, 1162 patients with a history of chronic low back
pain for a mean of 8 years were randomly assigned to real acupuncture, sham
acupuncture, or conventional therapy (a combination of drugs, physical
therapy, and exercise).47 Acupuncture treatments consisted of needle
insertions at standardized acupuncture points plus some additional points
chosen by the practitioner. Brief manual manipulation was used to stimulate
the needles after insertion. Sham acupuncture consisted of shallow insertion
of needles at non-acupuncture points without stimulation. The primary outcome
was a treatment response, defined as either a 33% improvement on the Von
Korff Chronic Pain Grade Scale or a 12% improvement on the Hannover
Functional Ability Questionnaire. At 6 months, there was no significant
difference between the response rate with real acupuncture (47.6%) and the
rate with sham acupuncture (44.2%; P=0.39), but both real and sham
acupuncture were significantly better than conventional therapy (27.4%;
P<0.001 for both comparisons).

A large trial in Germany,50 3093 patients with chronic low back pain for a
mean of 7 years were randomly assigned to receive either acupuncture or no
acupuncture in addition to usual medical care. The primary end point was back
function, as assessed with the use of the Hannover Functional Ability
Questionnaire, which generates a score ranging from 0 to 100, with 100
representing perfect back function. At 3 months, the mean back-function score
in the acupuncture group had increased from 61.8 to 74.5 (a mean increase of
12.1 points), and the mean score in the control group had increased from 63.3
to 65.1 (a mean increase of 2.7 points), for a difference in mean
between-group improvement of 9.4 points (95% confidence interval, 8.3 to
10.5; P<0.001)

這是有關一些Guideline:

The American College of Physicians and the American Pain Society have issued
joint clinical practice guidelines recommending that clinicians consider
acupuncture as one possible treatment option for patients with chronic low
back pain who do not have a response to self-care.68,69  The level of
supporting evidence for this recommendation was characterized as fair, and it
was noted that recommendations may change as new studies become available.

Furthermore, the North American Spine Society recently concluded that
acupuncture provides better short-term pain relief and functional improvement
than no treatment and that the addition of acupuncture to other treatments
provides a greater benefit than other treatments alone.70 This review also
identified a need for additional high-quality, randomized, controlled trials
comparing acupuncture with no treatment and with sham acupuncture. Finally,
the U.K. National Institute for Health and Clinical Excellence has
recommended acupuncture as a treatment option for patients with low back
pain. As a result, the U.K. National Health Service now provides a maximum of
10 sessions of acupuncture over a period of 12 weeks for people with low back
pain that has persisted for more than 6 weeks.71

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推 Robbie:good!
推 Luminoun:雖然是一樣的老問題沒解決。但至少這篇文章提供一定的客
→ Luminoun:觀性。
推 sls090:止痛
推 flamerecca:這篇文章...甚至沒有討論穴位@@
推 mark89:至少人家也承認這是 Chinese medicine 而不是 Korean XDD
推 lawfulevil:但如果這樣，那誰來戳有差別嗎？ 針灸師的角色是什麼？
推 myoma:tres bien
→ Luminoun:樓上嫌得人注意了，我說老問題都沒解決。但是，這篇的公
→ Luminoun:信力，遠比一堆中醫師或針灸師在那叫叫叫好多了。至少讓
→ Luminoun:大家以後有個客觀性的數據可以講，即使這些內容在我們而
→ Luminoun:仍然是非常不客觀和沒有任何臨床意義。
→ Luminoun:另外，這篇的主體是德國吧？要講好也得講德文。sehr gut.
→ Luminoun:law大，這篇文章對於針灸治療所謂『下背痛』，一點幫助都
→ Luminoun:沒有。你的所謂針灸師的角色問題，完全不成立。
→ Luminoun:這篇的結論，只能說，針灸對於慢性下背痛治療有助益，可
→ Luminoun:以作為治療選擇。它完全沒提到技術和診斷的差異性，所以
→ Luminoun:針灸技術對於療效的問題，一點也沒解答。
推 myoma:to L大大 小弟只是因為剛好在看法語片 突然間順口溜出來 我
→ myoma:當然知道這篇文章跟德國有關係
→ Luminoun:跟你鬧著玩。能一邊看法語片一邊看論文，超強！