Dr. Johnson is a primary care provider in the spinal cord injury clinic and Ms. Cosgrove works in quality management, both at the Orlando VAMC in Florida.
Pain intensity and pain relief was the treatment efficacy outcome for all the studies. A variety of measuring tools were reported across studies. Eight of the 13 studies reported measurement of pain intensity using the visual analog scale (VAS). 8,33,35-37,41-43 In addition to the VAS, 2 studies also used the numerical rating scale (NRS). 8,36 One study used the NRS alone. 38 Other studies used the McGill Pain Questionnaire 35; the SF-36 bodily pain dimension, Von Korff chronic pain grading scale, or low back pain rating scale 36; or the Western Ontario and McMaster Universities Osteoarthritis Index subscale for pain. 39,40,43
Authors from 8 of the systematic reviews and meta-analysis reported levels of evidence, or GRADE (Grades of Recommendation, Assessment, Development, and Evaluation), used to evaluate the overall quality of the evidence and the strength of the recommendations. 8,32,34-36,38,42,43 Levels of evidence were based on RCTs. The various levels were (1) “strong evidence,” consistent findings in multiple high-quality RCTs; (2) “moderate evidence,” consistent findings among multiple high-quality RTCs and/or 1 high-quality RCT; (3) “limited evidence,” low-quality RCT; (4) “conflicting evidence,” inconsistent findings among multiple RCTs; and (5) “no evidence,” no RCTs or no studies. 8,36
Most studies expressed the overall strength of the body of literature in 6 different categories: (1) “high quality,” confidence that the evidence reflected the true effect and that further research is very unlikely to change confidence in the effect of size; (2) “moderate quality,” further research is likely to have an impact on confidence in the estimate of effect and may change the estimate; (3) “low quality,” further research is very likely to have an important impact on confidence in the estimate of effect and is likely to change it; (4) “very low quality,” great uncertainty about the estimate; (5) “insufficient evidence,” either the evidence is unavailable or does not allow for a conclusion; and (6)“no evidence,” no evidence from RTCs. 32,34,35,38,42,43 Kwon and colleagues reported using a modified jaded score where a total of 5 points was awarded if a study was described as randomized, used an appropriate method, if subjects were blinded to the intervention, if the evaluator was blinded to the intervention, and if there was a description of withdrawals and dropouts. 43
Acupuncture
About 3 million American adults receive acupuncture each year. 44 The most commonly reported reason for its use is chronic pain. 44,45 Trials that examined the characteristics of those seeking and using acupuncture as adjunct to conventional treatment have found that patients who experienced positive outcomes, such as improvement in pain subscale, included females, previous failure of other therapies, and prior positive acupuncture encounters. 46
Six of the studies in this review examined the evidence of acupuncture for chronic low back pain. 35-38,41,42 Two of those studies found moderate evidence that acupuncture was more effective than no treatment for short-term pain relief. 35,36 Manheimer and colleagues found it to be significantly more effective than no additional treatment or sham treatment for short-term pain relief. 37 They however, reported a lack of evidence to suggest that it was more effective than were other active therapies. 37 Hutchinson and colleagues did not differentiate among data points for intermediate, short-term, or long-term follow-up in their study. 41 However, they concluded that there was some evidence to support acupuncture as more effective than no treatment and conflicting evidence of its effectiveness over other treatment modalities. Different levels of evidence were reported for intermediate pain relief with 2 of the other studies. One study found that the evidence was limited. 35 The other study reported conflicting evidence that it was more effective than no treatment for immediate pain relief for those with chronic low back pain. 36
