Acupucture in the treatment of scoliosis – a single blind controlled pilot study

Acupuncture involves penetration of the skin by thin, solid, metallic needles that are stimulated either manually or electrically. It is one of several Traditional Chinese Medicine (TCM) therapies that have been used for thousands of years in the treatment of a variety of health problems. Today, acupuncture therapy is commonly used for pain control throughout the world, although the putative mechanisms still are unclear [1].

TCM is a complete system of healthcare delivery including Qi Gong [2], herbal medicine [3, 4] and syndrome specific diets [4]. Therefore, a discussion of the efficacy of acupuncture must be prefaced with an understanding of the problems that occur when researchers attempt to evaluate treatments from one diagnostic paradigm (i.e., TCM) to diagnoses made with a different paradigm (i.e., allopathic medicine) [1]. Many studies have evaluated the use of acupuncture for symptoms that are either side effects of biomedical treatment (e.g., pain, fatigue) [1] or related to a specific disease process (e.g., OA). TCM syndromes, however, are not equivalent to either of these side effect types as defined by biomedical models. One must therefore use caution when interpreting results from studies that apply a TCM treatment to anything other than a TCM-related diagnosis or syndrome[1, 3–5].

TCM syndromes, such as yin/yang deficiencies or qi stagnation, are unique symptom complexes that result from imbalances between the body's various functional systems. Since TCM is based on functional relationships and TCM diagnoses involve syndromes not diseases, no one-to-one correlation of signs and symptoms between TCM diagnoses and biomedical diseases exists. The diagnostic symptom complexes used in TCM differ from an allopathic model, and treatment is given according to individual patterns of system imbalances [1].

Hundreds of clinical trials evaluating the efficacy of acupuncture for various conditions have been conducted and recently RCT studies have been published on pain syndromes [1]. Many studies, however, were poorly designed and few included treatment protocols as applied in actual clinical practice. Nevertheless, in some areas related to pain management, reviews provide sufficient evidence of efficacy to draw clear conclusions [1].

Since the early 1970s, the efficacy of acupuncture for treating clinical conditions has been evaluated in several hundred randomized trials [6–10]. Results from these trials have been synthesized in systematic reviews. However considerable methodological diversity exists in the comprehensiveness of database searches for Cochrane systematic reviews on acupuncture. This diversity makes the reviews prone to bias and adds another layer [11].

Also the German GERAC committee has published various studies about the effect of acupuncture in disorders like low back pain, Osteoarthritis of the knee and Migraine [12–19].

We have used acupucture during Scoliosis In-patient Rehabilitation (SIR) regularly for 7 years now for the treatment of back pain and we were wondering as to whether acupuncture could also be helpful in treating the deformity itself.

A Pub Med search for the key words "Acupuncture" and "Scoliosis"reveals 3 papers [20–22] not containing results of studies especially designed for the treatment of scoliosis with the help of acupucture. Because of this lack of trials designed for the treatment of scoliosis this pilot study has been performed.

Although the mechanisms of TCM are still unclear, the concept of the "energy channels" or meridians has been shown existent. The application of heat on certain acupuncture points did not lead to a spherical spreading of the heat around the spot, but to a longitudinal spreading along meridian-like pathways (Fig. 9 and 10) [29]. These findings speak for the existence of meridian like channels. However, in the scientific acupuncture community the existence of channels is not regarded as proven. This paper [29] is discussed heavily and has not been published in a Medline listed journal and has not been replicated.

In literature we can additionally find strong evidence that acupuncture may influence quite a number of pain syndromes [6–19] and therefore acupuncture has been applied for long also at this centre in patients with spinal deformities and pain [20]. Until now no acupuncture concept of treatment has been worked out for the treatment of the deformity itself. Having found some effect of acupuncture (significant improvement of surface rotation) in patients with curvatures on no more than 35 degrees in only one session has been surprising. In bigger patient samples significant results would have been expected for lateral deviation as well.

This finding has encouraged us to start a controlled study with scoliosis patients receiving a series of 6 acupuncture sessions during Scoliosis In-patient Rehabilitation (SIR).

Of course we have to take into account the technical error of the Formetric^®-system which is bigger than the average changes after the individual sessions. However we have differences that are at least in part statistically significant comparing the different interventions (L, S and R) and also medically relevant differences justifying preliminary conclusions. We have of course to accept that there are limitations of this study due to the relatively big technical error of the measuring system (15 – 20% for Lateral Deviation and Surface Rotation; 5% for Kyphosis Angle [25–28]), however postural sway cannot be regarded as a systematic error and therefore we would expect small changes not to be registered with the help of this device whereas clear tendencies or significant changes erase from the general variability and so are medically relevant. On the other hand there is no other device to measure the effects of exercises in short-term objectively other than x-rays not applicable for a study of this design because of the exposition to radiation.

When postural sway is not regarded as a systematic error all significant changes may be interpreted as being of medical relevance, while in the individual case the changes cannot be interpreted just by the values. The picture printed out on the Formetric^®-sheet (Fig. 7) therefore gives additional information, which however is also subject to postural sway.

There was a slight improvement of lateral deviation in the side lying intervention without any influence on surface rotation. This might be due to the fact that most of the curves were right thoracic and lying on the concavity unloads the curve without an influence on the deformity in 3D.

It has to be discussed why the changes seem relevant in the subgroup of patients with curvature of no more than 35 degrees while in the whole group of patients no relevant changes have been detected. As we know from certain brace studies bigger curves can be corrected not as easily as smaller curves [30, 31]. The reason therefore might be stiffness increasing with curve size and age [30, 31]. Therefore it might be possible that also patients with curvatures bigger than 35 degrees profit from a series of acupuncture.

In the very end it has to be discussed, as pointed out by Bunnel [32], that it has become apparent from many reports that, although there is a significant correlation between clinical deformity and radiographic measurement, the standard deviation is so high that it is not possible to reliably predict the degree of curvature from surface topography in any given patient by any technique" Bunnel [32] also states that, in general, clinical deformity is disproportionately greater than expected for the degree of Cobb angle in the early stages of the development of scoliosis.

One session with real (verum) acupuncture seems to have an influence on the deformity of scoliosis patients with no more than 35 degrees. The findings during verum acupuncture clearly are different to sham acupuncture or just lying, while in the whole group of patients also including patients with curvatures of more than 35 degrees no obvious changes have been found. The results of this study justify further investigation of the effect of acupuncture in the treatment of patients with scoliosis.