Acupressure for low back pain

Disability associated with low back pain is an important public health problem. Clinical trials carried out in the Western world show conventional treatment to have, at best, modest effects,1-3 and international guidelines agree only on the need to advise patients to remain physically active and prescribe appropriate pain medication.4 Other treatments that are evidence based and recommended for chronic low back pain, such as exercise and cognitive behaviour therapy, depend on substantial commitment and lifestyle change. It is therefore not surprising that patients seek alternative and complementary medicine in their search for pain relief, and a paper from Taiwan by Hsieh and colleagues on p 696 reports a randomised controlled trial of one such therapy—acupressure.5 In the United Kingdom, osteopathy and chiropractic are the types of complementary medicine most commonly sought by people with back pain,6 but therapies derived from the Chinese model of medicine are also popular. This model, which can be traced back at least 2500 years, considers all life to be empowered by an energy force (Qi) that flows around the body in pathways called meridians, providing mental and physical energy, maintaining health, and healing illness and injury. Energy flows are believed to be influenced by lifestyle (diet, exercise, and type of work, in particular) as well as external factors (damp or wind). Acupuncture (inserting needles into key points on these meridians with the aim of unblocking energy pathways and restoring internal balance) is often accompanied by advice on lifestyle. Selection of points may vary with practitioners' perceptions of the under-lying problems and the “school” or “tradition” of acupuncture they practice.7 A recent Cochrane review including 35 trials from Eastern and Western backgrounds found that, in patients with chronic back pain, acupuncture improved pain and function more than sham treatment or no treatment but was no more effective than other physical therapies.8 Acupressure is based on the same theoretical model as acupuncture but is non-invasive. It comprises gentle but firm pressure applied manually over meridian and acupuncture pressure points. The trial by Hsieh and colleagues compared six sessions of acupressure against a combination of various types of physiotherapy.5 It was well conducted in terms of randomisation, blinding, loss to follow-up, and analysis. The differences between the groups in standard outcome measures of disability, pain scores, and functional status are striking. The difference immediately after treatment and at six months was more than twice that reported in trials of conventional back pain interventions1-3 and of acupuncture.8 If these results are valid, acupressure would seem to represent an efficacious treatment for low back pain and we might need to ask why Chinese medicine clinicians use acupuncture for back pain, rather than acupressure. Are the results of this trial believable? Cultural differences are probably important in the experience and reporting of back pain, and Hsieh and colleagues do not say how they validated the English language outcome measures they used in their local population. The physiotherapy offered in one arm of the trial included a combination of interventions, some of which (thermotherapy, infrared light therapy, and traction) are not evidence based.4 Hence treatment in this group may have been suboptimal. As the authors discuss, patients' expectations and placebo effects are both likely to play a part in determining the outcome of interventions such as acupressure, and the additional benefits of acupressure cannot be established from this pragmatic trial.9,10 Perhaps the most important uncertainty about the results of this trial is the lack of clarity about the intervention. Although we know that all treatments were given by a single senior therapist, we do not know how experienced that person was. We are not told the school or tradition of acupressure that guided the practice of this therapist, which points he or she treated, or what lifestyle advice he or she gave patients. Although the trial by Hsieh and colleagues is interesting, external validity and implications for training need to be considered. We need to know whether other practitioners in Chinese medicine can achieve this level of success and how much the long term results depended on lifestyle changes. Would the effect be the same if Western clinicians were trained in these techniques, and would patients in the West with different cultures and lifestyles respond as well? The impact of patients' expectations and preferences on outcome also needs investigating to determine who is most likely to benefit. Physical therapy has been shown to be cost effective, despite small treatment effects, but such data do not exist for acupressure.11 The cost effectiveness of acupressure must be investigated before recommending that this treatment is used instead of evidence based physiotherapy for patients in the Western world. Given the public health importance of back pain, this evidence is needed sooner rather than later.