EDITORIAL For reprint orders, please contact: [email protected]
Complementary therapies for chronic pain: the case for acupuncture
“...acupuncture seems to be a potentially useful treatment in the pain physician’s armamentarium for at least some pain conditions in the short-to-medium term.” Karen J Sherman* Many patients with chronic pain turn to complementary therapies as part of their search for relief. In the USA, for example, use of complementary therapies was reported by 52% of 463 chronic patients in primary care (current use) [1] , 82% of veterans with chronic noncancer pain (ever used) [2] and 35–39% of patients attending pain clinics [3] . Among US users of complementary therapies, pain conditions, including back and neck pain, joint problems and arthritis, are among the ten most common reasons for use [4] . In a survey of Europeans with chronic pain, 69% of respondents used nondrug treatments [5] . Acupuncture was one of the most popular nondrug treatments (used by 13%). Acupuncture is a complementary medical therapy that has received considerable attention in western countries over the last few decades and is growing in popularity [4] . Like other complementary therapies, it is used frequently for chronic pain [6] . However, acupuncture remains contro versial among many researchers and some physicians. Why is this? An ideal treatment for pain would outperform placebo in efficacy trials, provide clear
clinical benefit under real life conditions, have a clearly understood biological mechanism, have a good safety record, be cost effective, be acceptable and accessible to patients and physicians, and facilitate or promote self-management. In addition, if used as part of an integrative treatment approach, it should lead to reductions in the use of harmful treatments. How does acupuncture perform when assessed using these criteria? Over 70 systematic reviews of acupuncture for a variety of pain conditions have been published [7] . Many of the primary studies have been small, poor quality trials. At least some of the systematic reviews for the same pain condition have come to opposite conclusions (e.g., temporomandibular disorder) [8,9] . Overall, acupuncture does not consistently outperform ‘placebo’ or ‘sham’ acupuncture [10,11] . In a meta-ana lysis using the gold standard of individual patient data from nearly 18,000 patients and 29 randomized trials, Vickers et al. found that the specific effects of acupuncture compared with sham were small and of questionable clinical significance [12] . Thus, acupuncture’s performance relative to placebo or sham is unclear.
“Acupuncture is a complementary medical therapy that has received considerable attention in western countries over the last few decades and is growing in popularity.”
*Group Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101, USA; Tel.: +1 206 287 2426; [email protected]
10.2217/PMT.12.73 © 2013 Future Medicine Ltd
Pain Manage. (2013) 3(1), 5–8
part of
ISSN 1758-1869
5
EDITORIAL Sherman
“Acupuncture is viewed favorably as a treatment in some US national surveys of physicians and pain specialists.”
6
There are, however, serious concerns about whether a true placebo or sham acupuncture treatment is actually possible [13] . Three types of placebo or sham acupuncture treatments have been used as comparison treatments in clinical trials of acupuncture: ‘misplaced needling’, ‘shallow needling’ and noninsertive ‘needling’. These treatments test different theories about how acupuncture is believed to work. Use of the first sham treatment implies that point specificity is the primary mechanism of acupuncture analgesia. Traditional acupuncturists use a wide variety of points for the treatment of pain. One common acupoint is the ‘ashi’ point (i.e., needle anywhere that is tender). This fact, coupled with the plethora of rationales, including some that are based on a western medical diagnosis, that acupuncturists use to select needle locations, suggests that using ‘inappropriate’ points is not an adequate control for acupuncture trials of pain conditions. Shallow needling would test the idea that needling depth is the key to acupuncture’s efficacy. However, such needling is used in many styles of Japanese acupuncture and so, use of such control groups is likely to be viewed as a comparison of different forms of acupuncture by at least some acupuncturists. Finally, noninsertive needling would test the need for needle insertion. However, it is used in some styles of traditional acupuncture. These concerns suggest that it may never be possible to compare acupuncture to a bona fide sham treatment. Rather, they suggest that many point prescriptions and types of acupoint stimulation are likely to be salubrious. A variety of systematic reviews and metaanalyses have clearly shown that acupuncture is superior to usual treatment for a number of chronic pain conditions, including back and neck pain, osteoarthritis, and headaches [12,13] . Effects sizes are consistent with modestto-moderate effects and are of clear clinical relevance. Some of these trials were pragmatic in nature and did an excellent job of simulating real world clinical practice. Thus, acupuncture seems to be a potentially useful treatment in the pain physician’s armamentarium for at least some pain conditions in the short-to-medium term. Much remains unclear about exactly how acupuncture works. Abundant evidence from animal studies suggests that endogenous opioids and other neurotransmitters are released during acupuncture treatment [14] , but we also know that they are implicated in placebo treatments
Pain Manage. (2013) 3(1)
as well. A systematic review with meta-analyses of verum acupuncture confirmed acupuncture’s association with modulation of brain activity, as detected by functional MRI [15] . Acupuncture seems to modulate activity within a variety of brain regions, including somatosensory cortices, the limbic system and areas of cognitive processing. However, a great deal of heterogeneity in terms of effects on the brain was observed across various studies. In turn, those studies differed greatly in study populations (healthy individuals vs patients), details of acupuncture needling, types of control groups and technical details of the experiments. In addition, verum and sham acupuncture are often associated with differences in brain activity. For example, although acupuncture had similar analgesic benefits for patients with fibromyalgia with both verum and sham needling, Harris et al. found differences in the binding capacity of mu opioid receptors after treatment depending on the type of needling [14] . Specifically, verum acupuncture increased the availability of mu opioid receptors in regions of the brain associated with analgesia (e.g., cingulate, insula and amygdala), while sham acupuncture decreased the availability of these receptors. Moreover, functional MRI studies have documented objective benefits of greater analgesia with positive expectations of acupuncture’s benefit [15] . Safety data from surveys and prospective studies with a total of nearly 3 million patients confirm its general safety [16] . Although serious adverse events, such as pneumothorax, have been reported after acupuncture, they are extremely rare (approximately one in 400,000). The majority of serious adverse events can be avoided by use of sterile, disposable needles, which is current practice in the West. A recent systematic review examined eight high-quality economic analyses conducted alongside randomized trials of acupuncture for various pain conditions [17] . In the seven studies looking at costs per quality-adjusted life year, costs were well below international thresholds for willingness to pay. In the other study, acupuncture was both cost saving and more effective than medications for prevention of migraines. Among acupuncture users, nearly half try it because conventional treatments have not worked for them [18] . Acupuncture is viewed favorably as a treatment in some US national surveys of physicians [19] and pain specialists [20] .
future science group
Complementary therapies for chronic pain: the case for acupuncture Acupuncture has been recommended or approved for use for chronic low back pain, by the American College of Physicians, the German Federal Committee of Physicians and Health Insurers, and the UK NICE [21] . NICE guidelines also recommend acupuncture for patients susceptible to migraine and tension headaches, but did not believe there was sufficient evidence regarding osteoarthritis. The German Federal Committee also recommended acupuncture for osteoarthritis but not headaches. In the US, acupuncture is not routinely reimbursed by insurers in most states. Access to coverage for acupuncture varies between countries, based on reimbursement or coverage patterns, so its potential value to patients is likely to vary. The optimal dose of acupuncture is currently unknown, and whether and how the dose interacts with other aspects of treatment, such as needling intensity and the use of ancillary therapies, such as heat, is also unknown. Although virtually all clinical trials test acupuncture either as a single therapy or as an add-on to ‘usual care’, in practice, acupuncture is rarely used alone. For example, in 78% of nearly 2600 visits to licensed acupuncturists, at least one additional treatment (e.g., heat or east Asian massage) was included with acupuncture [6] . In addition, self-care recommendations were made for two-thirds of the visits. Therefore, results References 1
2
3
4
Rosenberg EI, Genao I, Chen I et al. Complementary and alternative medicine use by primary care patients with chronic pain. Pain Med. 9, 1065–1072 (2008). Denneson LM, Corson K, Dobscha SK. Complementary and alternative medicine use among veterans with chronic noncancer pain. J. Rehabil. Res. Dev. 48, 1119–1128 (2011).
8
Konvicka JJ, Meyer TA, McDavid AJ, Roberson CR. Complementary/alternative medicine use among chronic pain clinic patients. J. Perianesth. Nurs. 23, 17–23 (2008). Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat. Report (12), 1–23 (2008).
5
Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur. J. Pain 10, 287–333 (2006)
6
Sherman KJ, Cherkin DC, Eisenberg DM, Erro J, Hrbek A, Deyo RA. The practice of
future science group
from many acupuncture trials may not represent its true value for patients. Although acupuncture is not a panacea and should be considered within the context of a multimodal approach to care, it has a place in contemporary pain practice. Acupuncture may reduce the need for medication use among some patients, which would be of clear value to patients for whom medications pose risks. It may help in dealing with flare-ups and encourage appropriate self-care. Acupuncture is delivered by numerous types of practitioners in the West and there is currently no data on which types of training lead to optimal outcomes. Although more precise information about optimal acupuncture treatments could enhance acupuncture care, the safety and benefit profile is sufficiently strong that acupuncture should be considered as a potential treatment for many patients with chronic pain. Financial & competing interests disclosure The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. acupuncture: who are the providers and what do they do? Ann. Fam. Med. 3, 151–158 (2005).
7
9
EDITORIAL
Vickers AJ, Cronin AM, Maschino AC et al. Individual patient data meta-analysis of acupuncture for chronic pain: protocol of the Acupuncture Trialists’ Collaboration. Trials 11, 90 (2010). La Touche R, Goddard G, De-la-Hoz JL et al. Acupuncture in the treatment of pain in temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials. Clin. J. Pain 26, 541–550 (2010). Turp JC. Limited evidence that acupuncture is effective for treating temporomandibular disorders. Evid. Based Dent. 12, 89 (2011).
10 Madsen MV, Gotzsche PC, Hrobjartsson A.
Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 338, a3115 (2009). 11 Langhorst J, Klose P, Musial F, Irnich D,
Hauser W. Efficacy of acupuncture in
fibromyalgia syndrome – a systematic review with a meta-analysis of controlled clinical trials. Rheumatology (Oxford) 49, 778–788 (2010). 12 Vickers AJ, Cronin AM, Maschino AC et al.
Acupuncture for chronic pain: individual patient data meta-analysis. Arch. Intern. Med. 10, 1–10 (2012). 13 Sherman KJ, Coeytaux RR. Acupuncture for
improving chronic back pain, osteoarthritis and headache. J. Clin. Outcome Manag. 16, 224–230 (2009). 14 Harris RE, Zubieta JK, Scott DJ, Napadow V,
Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on muopioid receptors (MORs). Neuroimage 47, 1077–1085 (2009). 15 Huang W, Pach D, Napadow V et al.
Characterizing acupuncture stimuli using brain imaging with FMRI – a systematic review and meta-analysis of the literature. PLoS ONE 7(4), e32960 (2012). 16 Witt CM, Lao L, MacPherson H. Evidence
on acupuncture safety needs to be based on
www.futuremedicine.com
7
EDITORIAL Sherman large-scale prospective surveys, not single case reports. Pain 152(2180), 4–6 (2011). 17 Ambrosio EM, Bloor K, MacPherson H.
Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials. Complement. Ther. Med. 20, 364–374 (2012).
8
18 Zhang Y, Lao L, Chen H, Ceballos R.
Acupuncture use among american adults: what acupuncture practitioners can learn from National Health Interview Survey 2007? Evid. Based Complement. Alternat. Med. 2012, 710750 (2012). 19 Chen L, Houghton M, Seefeld L, Malarick
C, Mao J. A survey of selected physician
Pain Manage. (2013) 3(1)
views on acupuncture in pain management. Pain Med. 11, 530–534 (2010). 20 Berman BM, Bausell RB. The use of non-
pharmacological therapies by pain specialists. Pain 85, 313–315 (2000). 21 Li A, Kaptchuk TJ. The case of acupuncture
for chronic low back pain: when efficacy and comparative effectiveness conflict. Spine 36, 181–182 (2011).
future science group
Complementary therapies for chronic pain: the case for acupuncture
“...acupuncture seems to be a potentially useful treatment in the pain physician’s armamentarium for at least some pain conditions in the short-to-medium term.” Karen J Sherman* Many patients with chronic pain turn to complementary therapies as part of their search for relief. In the USA, for example, use of complementary therapies was reported by 52% of 463 chronic patients in primary care (current use) [1] , 82% of veterans with chronic noncancer pain (ever used) [2] and 35–39% of patients attending pain clinics [3] . Among US users of complementary therapies, pain conditions, including back and neck pain, joint problems and arthritis, are among the ten most common reasons for use [4] . In a survey of Europeans with chronic pain, 69% of respondents used nondrug treatments [5] . Acupuncture was one of the most popular nondrug treatments (used by 13%). Acupuncture is a complementary medical therapy that has received considerable attention in western countries over the last few decades and is growing in popularity [4] . Like other complementary therapies, it is used frequently for chronic pain [6] . However, acupuncture remains contro versial among many researchers and some physicians. Why is this? An ideal treatment for pain would outperform placebo in efficacy trials, provide clear
clinical benefit under real life conditions, have a clearly understood biological mechanism, have a good safety record, be cost effective, be acceptable and accessible to patients and physicians, and facilitate or promote self-management. In addition, if used as part of an integrative treatment approach, it should lead to reductions in the use of harmful treatments. How does acupuncture perform when assessed using these criteria? Over 70 systematic reviews of acupuncture for a variety of pain conditions have been published [7] . Many of the primary studies have been small, poor quality trials. At least some of the systematic reviews for the same pain condition have come to opposite conclusions (e.g., temporomandibular disorder) [8,9] . Overall, acupuncture does not consistently outperform ‘placebo’ or ‘sham’ acupuncture [10,11] . In a meta-ana lysis using the gold standard of individual patient data from nearly 18,000 patients and 29 randomized trials, Vickers et al. found that the specific effects of acupuncture compared with sham were small and of questionable clinical significance [12] . Thus, acupuncture’s performance relative to placebo or sham is unclear.
“Acupuncture is a complementary medical therapy that has received considerable attention in western countries over the last few decades and is growing in popularity.”
*Group Health Research Institute, 1730 Minor Ave, Ste 1600, Seattle, WA 98101, USA; Tel.: +1 206 287 2426; [email protected]
10.2217/PMT.12.73 © 2013 Future Medicine Ltd
Pain Manage. (2013) 3(1), 5–8
part of
ISSN 1758-1869
5
EDITORIAL Sherman
“Acupuncture is viewed favorably as a treatment in some US national surveys of physicians and pain specialists.”
6
There are, however, serious concerns about whether a true placebo or sham acupuncture treatment is actually possible [13] . Three types of placebo or sham acupuncture treatments have been used as comparison treatments in clinical trials of acupuncture: ‘misplaced needling’, ‘shallow needling’ and noninsertive ‘needling’. These treatments test different theories about how acupuncture is believed to work. Use of the first sham treatment implies that point specificity is the primary mechanism of acupuncture analgesia. Traditional acupuncturists use a wide variety of points for the treatment of pain. One common acupoint is the ‘ashi’ point (i.e., needle anywhere that is tender). This fact, coupled with the plethora of rationales, including some that are based on a western medical diagnosis, that acupuncturists use to select needle locations, suggests that using ‘inappropriate’ points is not an adequate control for acupuncture trials of pain conditions. Shallow needling would test the idea that needling depth is the key to acupuncture’s efficacy. However, such needling is used in many styles of Japanese acupuncture and so, use of such control groups is likely to be viewed as a comparison of different forms of acupuncture by at least some acupuncturists. Finally, noninsertive needling would test the need for needle insertion. However, it is used in some styles of traditional acupuncture. These concerns suggest that it may never be possible to compare acupuncture to a bona fide sham treatment. Rather, they suggest that many point prescriptions and types of acupoint stimulation are likely to be salubrious. A variety of systematic reviews and metaanalyses have clearly shown that acupuncture is superior to usual treatment for a number of chronic pain conditions, including back and neck pain, osteoarthritis, and headaches [12,13] . Effects sizes are consistent with modestto-moderate effects and are of clear clinical relevance. Some of these trials were pragmatic in nature and did an excellent job of simulating real world clinical practice. Thus, acupuncture seems to be a potentially useful treatment in the pain physician’s armamentarium for at least some pain conditions in the short-to-medium term. Much remains unclear about exactly how acupuncture works. Abundant evidence from animal studies suggests that endogenous opioids and other neurotransmitters are released during acupuncture treatment [14] , but we also know that they are implicated in placebo treatments
Pain Manage. (2013) 3(1)
as well. A systematic review with meta-analyses of verum acupuncture confirmed acupuncture’s association with modulation of brain activity, as detected by functional MRI [15] . Acupuncture seems to modulate activity within a variety of brain regions, including somatosensory cortices, the limbic system and areas of cognitive processing. However, a great deal of heterogeneity in terms of effects on the brain was observed across various studies. In turn, those studies differed greatly in study populations (healthy individuals vs patients), details of acupuncture needling, types of control groups and technical details of the experiments. In addition, verum and sham acupuncture are often associated with differences in brain activity. For example, although acupuncture had similar analgesic benefits for patients with fibromyalgia with both verum and sham needling, Harris et al. found differences in the binding capacity of mu opioid receptors after treatment depending on the type of needling [14] . Specifically, verum acupuncture increased the availability of mu opioid receptors in regions of the brain associated with analgesia (e.g., cingulate, insula and amygdala), while sham acupuncture decreased the availability of these receptors. Moreover, functional MRI studies have documented objective benefits of greater analgesia with positive expectations of acupuncture’s benefit [15] . Safety data from surveys and prospective studies with a total of nearly 3 million patients confirm its general safety [16] . Although serious adverse events, such as pneumothorax, have been reported after acupuncture, they are extremely rare (approximately one in 400,000). The majority of serious adverse events can be avoided by use of sterile, disposable needles, which is current practice in the West. A recent systematic review examined eight high-quality economic analyses conducted alongside randomized trials of acupuncture for various pain conditions [17] . In the seven studies looking at costs per quality-adjusted life year, costs were well below international thresholds for willingness to pay. In the other study, acupuncture was both cost saving and more effective than medications for prevention of migraines. Among acupuncture users, nearly half try it because conventional treatments have not worked for them [18] . Acupuncture is viewed favorably as a treatment in some US national surveys of physicians [19] and pain specialists [20] .
future science group
Complementary therapies for chronic pain: the case for acupuncture Acupuncture has been recommended or approved for use for chronic low back pain, by the American College of Physicians, the German Federal Committee of Physicians and Health Insurers, and the UK NICE [21] . NICE guidelines also recommend acupuncture for patients susceptible to migraine and tension headaches, but did not believe there was sufficient evidence regarding osteoarthritis. The German Federal Committee also recommended acupuncture for osteoarthritis but not headaches. In the US, acupuncture is not routinely reimbursed by insurers in most states. Access to coverage for acupuncture varies between countries, based on reimbursement or coverage patterns, so its potential value to patients is likely to vary. The optimal dose of acupuncture is currently unknown, and whether and how the dose interacts with other aspects of treatment, such as needling intensity and the use of ancillary therapies, such as heat, is also unknown. Although virtually all clinical trials test acupuncture either as a single therapy or as an add-on to ‘usual care’, in practice, acupuncture is rarely used alone. For example, in 78% of nearly 2600 visits to licensed acupuncturists, at least one additional treatment (e.g., heat or east Asian massage) was included with acupuncture [6] . In addition, self-care recommendations were made for two-thirds of the visits. Therefore, results References 1
2
3
4
Rosenberg EI, Genao I, Chen I et al. Complementary and alternative medicine use by primary care patients with chronic pain. Pain Med. 9, 1065–1072 (2008). Denneson LM, Corson K, Dobscha SK. Complementary and alternative medicine use among veterans with chronic noncancer pain. J. Rehabil. Res. Dev. 48, 1119–1128 (2011).
8
Konvicka JJ, Meyer TA, McDavid AJ, Roberson CR. Complementary/alternative medicine use among chronic pain clinic patients. J. Perianesth. Nurs. 23, 17–23 (2008). Barnes PM, Bloom B, Nahin RL. Complementary and alternative medicine use among adults and children: United States, 2007. Natl Health Stat. Report (12), 1–23 (2008).
5
Breivik H, Collett B, Ventafridda V, Cohen R, Gallacher D. Survey of chronic pain in Europe: prevalence, impact on daily life, and treatment. Eur. J. Pain 10, 287–333 (2006)
6
Sherman KJ, Cherkin DC, Eisenberg DM, Erro J, Hrbek A, Deyo RA. The practice of
future science group
from many acupuncture trials may not represent its true value for patients. Although acupuncture is not a panacea and should be considered within the context of a multimodal approach to care, it has a place in contemporary pain practice. Acupuncture may reduce the need for medication use among some patients, which would be of clear value to patients for whom medications pose risks. It may help in dealing with flare-ups and encourage appropriate self-care. Acupuncture is delivered by numerous types of practitioners in the West and there is currently no data on which types of training lead to optimal outcomes. Although more precise information about optimal acupuncture treatments could enhance acupuncture care, the safety and benefit profile is sufficiently strong that acupuncture should be considered as a potential treatment for many patients with chronic pain. Financial & competing interests disclosure The author has no relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript. This includes employment, consultancies, honoraria, stock ownership or options, expert testimony, grants or patents received or pending, or royalties. No writing assistance was utilized in the production of this manuscript. acupuncture: who are the providers and what do they do? Ann. Fam. Med. 3, 151–158 (2005).
7
9
EDITORIAL
Vickers AJ, Cronin AM, Maschino AC et al. Individual patient data meta-analysis of acupuncture for chronic pain: protocol of the Acupuncture Trialists’ Collaboration. Trials 11, 90 (2010). La Touche R, Goddard G, De-la-Hoz JL et al. Acupuncture in the treatment of pain in temporomandibular disorders: a systematic review and meta-analysis of randomized controlled trials. Clin. J. Pain 26, 541–550 (2010). Turp JC. Limited evidence that acupuncture is effective for treating temporomandibular disorders. Evid. Based Dent. 12, 89 (2011).
10 Madsen MV, Gotzsche PC, Hrobjartsson A.
Acupuncture treatment for pain: systematic review of randomised clinical trials with acupuncture, placebo acupuncture, and no acupuncture groups. BMJ 338, a3115 (2009). 11 Langhorst J, Klose P, Musial F, Irnich D,
Hauser W. Efficacy of acupuncture in
fibromyalgia syndrome – a systematic review with a meta-analysis of controlled clinical trials. Rheumatology (Oxford) 49, 778–788 (2010). 12 Vickers AJ, Cronin AM, Maschino AC et al.
Acupuncture for chronic pain: individual patient data meta-analysis. Arch. Intern. Med. 10, 1–10 (2012). 13 Sherman KJ, Coeytaux RR. Acupuncture for
improving chronic back pain, osteoarthritis and headache. J. Clin. Outcome Manag. 16, 224–230 (2009). 14 Harris RE, Zubieta JK, Scott DJ, Napadow V,
Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on muopioid receptors (MORs). Neuroimage 47, 1077–1085 (2009). 15 Huang W, Pach D, Napadow V et al.
Characterizing acupuncture stimuli using brain imaging with FMRI – a systematic review and meta-analysis of the literature. PLoS ONE 7(4), e32960 (2012). 16 Witt CM, Lao L, MacPherson H. Evidence
on acupuncture safety needs to be based on
www.futuremedicine.com
7
EDITORIAL Sherman large-scale prospective surveys, not single case reports. Pain 152(2180), 4–6 (2011). 17 Ambrosio EM, Bloor K, MacPherson H.
Costs and consequences of acupuncture as a treatment for chronic pain: a systematic review of economic evaluations conducted alongside randomised controlled trials. Complement. Ther. Med. 20, 364–374 (2012).
8
18 Zhang Y, Lao L, Chen H, Ceballos R.
Acupuncture use among american adults: what acupuncture practitioners can learn from National Health Interview Survey 2007? Evid. Based Complement. Alternat. Med. 2012, 710750 (2012). 19 Chen L, Houghton M, Seefeld L, Malarick
C, Mao J. A survey of selected physician
Pain Manage. (2013) 3(1)
views on acupuncture in pain management. Pain Med. 11, 530–534 (2010). 20 Berman BM, Bausell RB. The use of non-
pharmacological therapies by pain specialists. Pain 85, 313–315 (2000). 21 Li A, Kaptchuk TJ. The case of acupuncture
for chronic low back pain: when efficacy and comparative effectiveness conflict. Spine 36, 181–182 (2011).
future science group
