~침술요법 '만성적 통증치료 효과있다'[LA중앙일보]
국립보건원 연구결과 발표
기사입력: 09.11.12 20:38
침술요법이 만성적 통증 치료에 효과적이라는 연구 결과가 발표됐다.
이 연구 결과는 다수 보험사들이 침술요법을 보험 적용 대상에서 제외하고 있는 가운데 나온 것이어서 향후 보험 적용 대상 확대가 이루어질 경우 긍정적 영향을 미칠 것으로 기대된다.
국립보건원은 지난 5년 동안 미국과 유럽에서 허리와 목 어깨 통증 두통 등으로 침술요법 시술을 받은 1만7922여 환자의 통증 개선 효과를 분석한 연구 결과를 11일 발표하고 "분석 가능한 29건의 연구 사례를 조사한 결과 침술이 통증 치료에 실질적인 효과가 있다는 결론을 내렸다"고 밝혔다. 적지 않은 현대 의학 전문가들이 침술 효과를 부정하며 "환자들의 심리 효과로 인한 일시적 통증완화 이른바 '플라시보 효과'"라고 폄하해온 상황에서 국립보건원이 침술의 효능을 인정한 것이다. 이번 논문은 의학전문지인 '내과의학자료집(Archives of Internal Medicine)' 9월호에 실렸다.
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Acupuncture Does Help for Chronic Pain
By Nancy Walsh, Staff Writer, MedPage Today
Published: September 10, 2012
Reviewed by Zalman S. Agus, MD; Emeritus Professor, Perelman School of Medicine at the University of Pennsylvania and Dorothy Caputo, MA, BSN, RN, Nurse Planner
•Note that in this meta-analysis, investigators found a statistically significant benefit of acupuncture for relief of chronic pain due to a variety of causes when compared with both sham controls and usual-care controls.
•Point out that the pain relief was much greater when acupuncture was compared with usual care than when compared with the sham suggesting a role for a placebo effect.
Acupuncture provides more relief from various types of chronic pain than does usual care and should be considered a valid therapeutic option, the authors of a meta-analysis concluded.
For back and neck pain, osteoarthritis, and chronic headache, pain scores among patients treated with acupuncture were 0.23 (95% CI 0.13 to 0.33), 0.16 (95% CI 0.07 to 0.25) and 0.15 (95% CI 0.07 to 0.24) standard deviations below the scores for patients receiving sham acupuncture (P<0.001 for all), according to Andrew J. Vickers, DPhil, of Memorial Sloan-Kettering Cancer Center in New York City, and colleagues.
But effect sizes were even larger when acupuncture was compared with no acupuncture, with scores of 0.55 (95% CI 0.51 to 0.58), 0.57 (95% CI 0.50 to 0.64), and 0.42 (95% CI 0.37 to 0.46) standard deviations lower (P<0.001 for all), the researchers reported online in Archives of Internal Medicine.
Acupuncture is recognized as having certain physiologic effects that can contribute to pain relief, but no plausible mechanism has been identified that could lead to long-term benefits for chronic pain, with the result that the treatment remains "highly controversial," according to the researchers.
Many controlled studies of acupuncture for pain have been published, but quality has been inconsistent and reliability has been questioned.
To provide more clarity about the effects of acupuncture on pain, Vickers and colleagues conducted an individual patient data meta-analysis based exclusively on high quality randomized trials.
Included trials required pain of at least a month's duration, with the primary endpoint being assessed at least a month after acupuncture treatment began.
The researchers were able to acquire the original raw data for 29 studies that included 17,922 patients.
To explain the clinical significance of the effect sizes found in the meta-analyses, they noted that a typical pain score in a clinical trial might be 60 on a 100-point scale.
If the standard deviation was assumed to be 25, scores after treatment could be 30 for true acupuncture, 35 for sham acupuncture, and 43 for no acupuncture, they estimated.
Another way of looking at this would be that if response was categorized as a decrease in pain of 50%, response rates would be 50% for true acupuncture compared with 42.5% and 30% for sham acupuncture and no acupuncture, respectively.
"The average effect, as expressed in the meta-analytic estimate of approximately 0.5 [standard deviations], is of clear clinical relevance whether considered either as a standardized difference or when converted back to a pain scale," Vickers and colleagues stated.
They noted that there was significant heterogeneity in a number of the analyses, particularly in the control groups of the various studies.
In some trials, for example, patients in the usual-care control groups were permitted to have rescue analgesics only, while in other studies there were exercise and physical therapy programs.
Moreover, in the sham acupuncture trials, different approaches were permitted, such as using nonpenetrating needles and using non-needle methods such as inactive electrical stimulation.
Other limitations of the meta-analysis included the possibility of bias when acupuncture was compared with no acupuncture and the use of different endpoints in some trials.
Nonetheless, the authors stated that their findings should be considered "both clinically and scientifically important."
They noted that many clinicians would be unwilling to refer a patient for acupuncture if the effects derived only from the nonspecific belief on the part of the patient that the treatment would help.
But the finding that true acupuncture had significantly greater effects than the sham indicates that the effects of the do extend beyond placebo, they observed.
This is "of major importance for clinical practice," meaning that acupuncture should be considered "a reasonable referral option for patients with chronic pain," they stated.
In an invited commentary accompanying the meta-analysis, Andrew L. Avins, MD, of Kaiser-Permanente in Oakland, Calif., argued that the benefits indeed were primarily those associated with the placebo effect, because the pain relief was so much greater when acupuncture was compared with usual care than when compared with the sham .
But whether that should mean acupuncture has no value for patients, largely because of uncertainty as to its mechanisms of action, is a crucial concern, he pointed out.
"The ultimate question is: does this intervention work (or, more completely, do its benefits outweigh its risks and justify its cost)?" Avins wrote.
For acupuncture, the current meta-analysis offers "some robust evidence" that acupuncture does provide greater chronic pain relief than usual care, mechanisms of effect aside.
"Perhaps a more productive strategy at this point would be to provide whatever benefits we can for our patients, while we continue to explore more carefully all mechanisms of healing," Avins concluded.
Funding for this work was provided by the National Center for Complementary and Alternative Medicine, the Samueli Institute, and the U.K. National Institute for Health Research.
Authors and editorialist all reported no financial disclosures.
Primary source: Archives of Internal Medicine
Vickers A, et al "Acupuncture for chronic pain: individual patient data meta-analysis" Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.3654.
Additional source: Archives of Internal Medicine
Avins A "Needling the status quo" Arch Intern Med 2012; DOI: 10.1001/archinternmed.2012.4198.
Acupuncture works, one way or another
By Amanda Gardner, Health.com
updated 1:09 PM EDT, Tue September 11, 2012
Acupuncture relieves pain, studies show, but some believe it's partly a "placebo effect."
•Researchers analyzed data from 29 clinical trials
•They conclude the pain relief is partly real -- not the placebo effect
•Acupuncture involves placing needles in specific locations to treat ailments
•Some believe the majority of relief is still a placebo effect
(Health.com) -- Many people with chronic pain swear by acupuncture, but skeptics of the ancient needle-based treatment have long claimed that it's little more than an elaborate placebo.
A new study published this week in the Archives of Internal Medicine appears to at least somewhat vindicate the acupuncture believers.
After re-analyzing data from 29 high-quality clinical trials dating back to the 1990s, researchers have concluded that the pain relief derived from acupuncture is partly real, in that it can't be ascribed entirely to the placebo effect.
The trials, which included roughly 18,000 people with chronic pain stemming from arthritis, headaches, or back and neck problems, all compared genuine acupuncture with one of two alternatives: treatment as usual, or "sham" acupuncture -- a counterfeit (i.e. placebo) version of the treatment in which needles are inserted unsystematically.
Pain relief of 50% or more on a 100-point scale -- pain that drops from a 60 to a 30, say -- is a commonly used standard of effectiveness in pain research. By this measure, the study found, the effectiveness rates for real acupunture, sham acupuncture, and treatment as usual are 50%, 43%, and 30%, respectively.
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"Most clinicians and patients would say a 50% success rate versus a 30% success rate for something like intractable chronic pain is actually pretty good," says lead author Andrew J. Vickers, a statistician at Memorial Sloan-Kettering Cancer Center in New York.
Acupuncture, which originated in China, involves placing needles in specific locations or "meridians" of the body in order to treat various ailments, especially pain. Acupuncture practitioners claim the technique relieves pain by modifying energy flow through the body.
"Acupuncturists talk about concepts coming from outside traditional biomedicine," Vickers explains. "Doctors will say, 'I didn't learn about energy flow in Physiology 101.'"
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The energy-flow theory has met with a great deal of skepticism in the United States and other Western nations, and researchers have failed to identify other, biological underpinnings for the treatment.
Dozens of clinical trials have sought to prove that acupuncture is more than a placebo by comparing the real thing with sham treatments, which in addition to misplaced needles can include electrical or laser stimulation designed to mimic pinpricks.
The new study bolsters the evidence for acupuncture but doesn't quite put to rest the idea that patients are largely responding to the placebo effect, says Dr. Andrew L. Avins, an epidemiologist at the University of California, San Francisco and a research scientist at Kaiser Permanente, a large nonprofit health plan based in Oakland, California.
Although genuine acupuncture clearly benefited the study participants, Avins says, the fact that the effectiveness rate was much higher than treatment as usual but only slightly higher than the sham treatment suggests that most of the benefit associated with acupuncture is indeed attributable to the placebo effect.
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What's more, he adds, the modest difference between genuine and sham acupuncture may not be meaningful for the average real-world patient.
"Acupuncture does appear to have some very small benefit above and beyond placebo acupuncture or sham acupuncture," says Avins, who wrote an editorial accompanying the study. "But the effects really are pretty small, and the majority of the effect is a placebo effect."
Acupuncture skeptics will likely seize on this point, Avins says, but the study findings don't mean that acupuncture doesn't work, or that doctors shouldn't refer pain patients for the treatment.
Acupuncture, he suggests, should perhaps be viewed as a way of providing modest pain relief while also harnessing the placebo effect.
"In the past, people have viewed placebos as negative things, (but) they could have some real benefits for patients," Avins says. "I would be hard-pressed to tell a patient who says they're benefiting from something that's 'just a placebo' to stop using it."
Archives of Internal Medicine | Acupuncture for ...
Review Article | ONLINE FIRST
Acupuncture for Chronic Pain: Individual Patient Data Meta-analysis ONLINE FIRST
Andrew J. Vickers, DPhil; Angel M. Cronin, MS; Alexandra C. Maschino, BS; George Lewith, MD; Hugh MacPherson, PhD; Nadine E. Foster, DPhil; Karen J. Sherman, PhD; Claudia M. Witt, MD; Klaus Linde, MD; for the Acupuncture Trialists' Collaboration
Arch Intern Med. Published online September 10, 2012. doi:10.1001/archinternmed.2012.3654
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Published online September 10, 2012
ABSTRACT | METHODS | RESULTS | COMMENT | AUTHOR INFORMATION | REFERENCES
Background Although acupuncture is widely used for chronic pain, there remains considerable controversy as to its value. We aimed to determine the effect size of acupuncture for 4 chronic pain conditions: back and neck pain, osteoarthritis, chronic headache, and shoulder pain.
Methods We conducted a systematic review to identify randomized controlled trials (RCTs) of acupuncture for chronic pain in which allocation concealment was determined unambiguously to be adequate. Individual patient data meta-analyses were conducted using data from 29 of 31 eligible RCTs, with a total of 17 922 patients analyzed.
Results In the primary analysis, including all eligible RCTs, acupuncture was superior to both sham and no-acupuncture control for each pain condition (P < .001 for all comparisons). After exclusion of an outlying set of RCTs that strongly favored acupuncture, the effect sizes were similar across pain conditions. Patients receiving acupuncture had less pain, with scores that were 0.23 (95% CI, 0.13-0.33), 0.16 (95% CI, 0.07-0.25), and 0.15 (95% CI, 0.07-0.24) SDs lower than sham controls for back and neck pain, osteoarthritis, and chronic headache, respectively; the effect sizes in comparison to no-acupuncture controls were 0.55 (95% CI, 0.51-0.58), 0.57 (95% CI, 0.50-0.64), and 0.42 (95% CI, 0.37-0.46) SDs. These results were robust to a variety of sensitivity analyses, including those related to publication bias.
Conclusions Acupuncture is effective for the treatment of chronic pain and is therefore a reasonable referral option. Significant differences between true and sham acupuncture indicate that acupuncture is more than a placebo. However, these differences are relatively modest, suggesting that factors in addition to the specific effects of needling are important contributors to the therapeutic effects of acupuncture.