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Posts Tagged ‘traditional chinese medicine’

Dear President Aquino

February 16th, 2011 3 comments

I would like to point out a slight error in your statements as quoted here: http://www.gmanews.tv/story/213171/chinese-embassy-court-sustains-death-sentence-on-3-pinoys

“(A Chinese ambassador told me that) they are very, very strict when it comes to drug laws because it’s a major concern of theirs. Iyung sa shabu, iyung ephedrine is a natural, comes from a plant that grows primarily in China. Mas malaki ang problema nila doon, they have a bigger populace, and they have syempre the history of opium from before,”

Why the heck is ephedrine mentioned in the same breath as methamphetamines and opium?  Again this is due to Ephedra’s bad rep as it is banned in the United States.  I shan’t repeat myself, but I would like to refer our President to my articles about Ephedra:

“News Bias Continues: Ephedra’s True Story” http://qi-spot.com/2010/02/01/news-bias-continues-ephedras-true-story/

.581px Ephedra andina 1 290x300 Dear President Aquino

A quote:

Herba Ephedrae or Ma Huang is usually the first herb one would see in a typical textbook of Chinese herbal medicine.  It is usually used to clear early symptoms of flu, and not ALL kinds of flu.  ANY look at the texts will give SPECIFIC indications for it’s use.  However, western herb enthusiasts had, according to the article, “converted from an herbal treatment for diseases to an energy stimulant and a weight-loss product.”

What are it’s classic textbook uses?

Actions: induces diaphoresis, resolves surface, ventilates the lungs to relieve asthma, regulates water metabolism.

Applications: febrile diseases due to exterior-excess, fever, chillphobia [aversion to cold], anhidrosis [lack of perspiration], ostealgia [bone pain], arthralgia, cough with dyspnea, edema, edema due to wind.

From this, it becomes obvious that Herba ephedrae is meant to be used in actual illness, not in a healthy person just trying to get a kick or lose weight.  The weight loss aspect is gleaned from it’s strong diaphoretic effect.  However, a basic look at any  Chinese herbal textbook will show that administration of ma huang should stop WHEN PERSPIRATION BEGINS, whether or not the flu has dispersed.

Again, if the patient has external symptoms (chills, slight fever, arthralgia, muscle pain) with no sweating, ma huang may be given AS PART OF A FORMULA to mediate effects (see ma huang tang, among others) and should be STOPPED when sweating begins.

Also, it should not be used as a tonic.  Many of the early ma huang/ephedra “supplements” were mixtures of ephedra and other tonics (including caffeine!)  Disaster waiting to happen.

How does that compare with western enthusiasts taking the herb individually for what we MDs would term as “off label use” contrary to all warnings?

OF COURSE they’ll get sick.  A professor of mine in China warned against yin collapse (shock due to blood or fluid loss) after using too much sweat-inducing herbs.

“The Art of Chinese Medicine” http://qi-spot.com/2010/11/15/the-art-of-chinese-medicine/

My point, Mr. President, is that Ma Huang or ephedra, the source of ephedrine, is a very valuable medicinal material in China and is banned in the US only because SOME IDIOTS misused it for off-label purposes.  It does not deserve to be compared to real dangerous drugs

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Defining Placebo: the Saint Jude Thaddeus of Medical Terminology

February 15th, 2011 No comments

I have recently begun calling the placebo effect the Saint Jude Thaddeus of Medical Terminology.  This is not because placebo effects are miraculous – although they might sometimes seem to be – but because the placebo effect (or things even remotely connected to it) has gotten a bad rap for something it didn’t do. So what’s the connection to Saint Jude?  Note this excerpt from a traditional prayer:

…faithful servant and friend of  Jesus, the name of the traitor who delivered your beloved Master into the hands of the enemies has caused you to be forgotten by many, but the Church honors and invokes you universally as the patron of hopeless cases and of things despaired of…

stjude Defining Placebo: the Saint Jude Thaddeus of Medical Terminology So basically, Judas Thaddeus got a bad rap because of Judas Iscariot, so much so that there are now two ways of translating the name into English, Judas and Jude. So what does this have to do with placebo?  First we define placebo and placebo effect:

Placebo:
a. a substance having no pharmacological effect but given merely to satisfy a patient who supposes it to be a medicine.
b. a substance having no pharmacological effect butadministered as a control in testing experimentally or clinically the efficacy of a biologically active preparation.
Placebo effect:
a reaction to a placebo manifested by a lessening of symptoms or the production of anticipated side effects.
Hence, what is at play here: first, a true placebo must have NO BIOLOGICAL EFFECT.  You give it and there should be no physiologic change in the body.
Here are some beauts from the article:
In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.”
The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”
In Acupuncture For Chronic Low Back Pain, the authors reviewed clinical trials done to assess if acupuncture actually helps in chronic low back pain. The most important meta-analysis available was a 2008 study involving 6,359 patients, which “showed that real acupuncture treatments were no more effective than sham acupuncture treatments.” The authors then editorialized: “There was nevertheless evidence that both real acupuncture and sham acupuncture were more effective than no treatment and that acupuncture can be a useful supplement to other forms of conventional therapy for low back pain.”
Okay, Mr Ho, the author, correctly states that the studies show that real acupuncture and sham acupuncture both have a better effect than no acupuncture.  The problem with this meta analysis is that the definitions of sham are not universal, as correctly pointed out by at least one commenter “japariesw”:
Dear writer (Mr. Ho), this controversy emerges from clinical trials comparing real and sham acupuncture. What you did not elaborate in your article is what is meant by ‘sham’ acupuncture? As acupuncture can be done not merely by piercing needles like in the photo, but also using laser, ultrasound, even with pressure or touch/ stroking the body surface. So, is the ‘sham’ acupuncture really sham? The modality of action is through neurophysicoendocrine pathway, by any modes of stimuli like stroking, piercing, etc. our body will react by showing the therapeutic effects like wellbeing, pain relieving, blood pressure downregulating (for hypertension, but not for normotensive)
So what the commenter is saying is that acupuncture is not just sticking needles in.  I’ve blogged on this topic extensively.  Also, sham still involves either putting needles in, albeit in false points, or stroking the skin.  Either way, neuro pathways are activated and thus, there is still a net physiologic effect.  Yet Mr. Ho says:
First, they admit that pooled clinical trials of the best sort show that real acupuncture does no better than sham acupuncture. This should mean that acupuncture does not work – full stop. But then they say that both sham and real acupuncture work as well as the other and thus is useful. Translation: Please use acupuncture as a placebo on your patients; just don’t let them know it is a placebo.
The authors trotted out the same conclusion after they reviewed an important German trial which also showed acupuncture to be merely a placebo.
Note how Mr. Ho  - loves to hammer the word home: Placebo placebo placebo! Yet there are some points of his that deserve critique.  He says that acupuncture is “no better” than sham.  That is not true.  I’ve seen those studies, they are slightly better than sham.  Second, he says that that “should mean acupuncture does not work” – that is skipping too many steps in the thinking process, and a perfect illustration of my article’s point.
Acupuncture no better than sham = acupuncture is placebo = it doesn’t work. This is their creed.
As long as a physiologic effect is seen, then by definition it cannot be a placebo.  Since there are physiologic effects (albeit different ones, which I mention in my above quoted blog posts) in both sham and real acupuncture, then even sham acupuncture is not a true placebo.
Also, I want to take a closer look at placebo.  By definition it doesn’t mean doing nothing, it means no physiologic effect yet the patient having a perceived OR REAL benefit.  Hence, if I wave my hands and nothing happens it’s not placebo.  If I dress well in clinic, with my dapper tie and crisp white white coat, speak with kind, reassuring words, and the patient already feels a bit better, that’s placebo.  Heck, there is a scene from the first season of Scrubs where the main female character flashes her breasts at a patient and the patient recovers.
And doctors do that all the time – use this placebo effect.  Why? Because a placebo effect is a placebo effect only if there is a perceived or real benefit – it is ERRONEOUS to say that placebo means no effect.
Yet placebo has become a buzzword for skeptics to attack acupuncture despite the fact that it cannot possibly apply to acupuncture.
Ho heaves on:
In any randomized and blinded clinical trial of any mode of treatment for any condition, the finding that the treatment is no better than a placebo always leads to one conclusion only: It is therapeutically useless. Acupuncture, it would seem, is exempted from this rule.
Again, this is true if sham acupuncture is a true placebo, meaning it has no physiologic effect.  Common sense shows that merely touching the skin creates physiologic responses.
The rest of the article by Ho elaborates on the skeptic’s next usual attack on acupuncture and chinese medicine: it is based on astrology and thus cannot work.
For someone with a Chinese surname, I find it appalling that Ho can have such a misconception about what Qi is:
In Chinese cosmology, all life is animated by a numinous force called qi, the flow of which mirrors the sun’s apparent “movement” during the year through the ecliptic. (The ecliptic is the imaginary plane of the earth’s orbit around the sun).
Qi flow does not mirror the sun’s movement.  Duh  See my immediately preceding article for explaining what Qi is.
Moreover, everything in the Chinese zodiac is mirrored on Earth and in Man. This was taught even in the earliest systematised TCM text, the Yellow Emperor’s Canon Of Medicine, thus: “Heaven is covered with constellations, Earth with waterways, and man with channels.”
If we translated channels as blood vessels, which is a possible interpretation, would Ho be so fast as to make a supernatural component?  The mythical author of the Canon was merely using words to help the reader grasp the concept.  Instead of focusing on “waterways” Ho focuses on “constellations”
This means that if there is qi flowing around in the imaginary closed loop of the zodiac, there is qi flowing correspondingly in the body’s closed loop of imaginary meridians as well.
These meridians run from head to toe to form a network interlinking 361 points on the skin. But why are there 361 points? Since the earth takes three minutes under 24 hours to rotate 360 degrees on its axis, the sun appears to revolve through 361 degrees on the ecliptic every 24 hours. Hence 361 points. This factoid alone is sufficient to nail down the acupuncture-astrology linkage.
Since qi flows around in a closed loop, needles can be inserted at one of these points far removed from your site of pain to rechannel qi. If done well, this supposedly can cure your spot of trouble.
Who said there are 361 points?  There are more than 400.  In the Yellow Emperor’s Canon, less than 200 are mentioned.  The point is that it evolved through time, not the product of some mathemagician. Therefore, for Mr. Ho to attempt to use acupuncture point number to try to create a numerology reference is out of date.  Also, no studious TCM practitioner will say that Qi flows in a “closed loop”.  Qi interacts with environment.
It’s arguably OXYGEN or breath.  Would we say oxygen flows in our body in a closed loop?
His last line: “So should doctors check the daily horoscopes of their patients?”
My answer: I certainly don’t.
Poor poor placebo effect, it’s gotten a bad rap.
Maybe we should ask St. Jude to help enlighten the minds who know not the Placebo effect and don’t bother to really learn about TCM before trying to debunk it.
References:
“placebo.” Dictionary.com Unabridged. Random House, Inc. 14 Feb. 2011. <Dictionary.com http://dictionary.reference.com/browse/placebo>
“placebo effect.” Dictionary.com Unabridged. Random House, Inc. 14 Feb. 2011.
Ho, Andy “Pinning down Acupuncture: It’s an Illusion” 13 Feb 2001 <http://www.thejakartaglobe.com/home/pinning-down-acupuncture-its-an-illusion/422438>
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“Warning Issued On Chinese Medicine”

November 17th, 2010 1 comment

Yes, that’s the title of an article published today in the Philippine Star.  (http://www.philstar.com/Article.aspx?articleId=630865&publicationSubCategoryId=63)

The way the headline is written, one would think that the warning issued was against Chinese Medicine as in Chinese Medicine the tradition, such as the medicine I practice.  It does not say “Warning Issued On Chinese Medicines” or “Warning Issued on Fake Chinese Medicine”.  No, it uses the general term “Warning Issued on Chinese Medicine”.

I will quote the article in full here:

MANILA, Philippines – People are urged to exercise caution when taking Chinese medicine.

Speaking to reporters, Leonila Ocampo, Philippine Pharmaceutical Association (PPA) president, said many Chinese medicinal and herbal products are not registered with the Food and Drug Administration (FDA).

Therefore they are considered counterfeit, although legitimate in the country where they were manufactured, she added.

Under Republic Act 8203, or the Special Law on Counterfeit Drugs, fake medicine pertains to unregistered imported drug products, Ocampo said.

Dr. Minerva Calimag, Philippine Medical Association (PMA) food, drugs and cosmetics committee chairman, said security in the country’s coasts is weak, enabling smugglers to bring in counterfeit medicine.

“If fake drugs are coming from outside (the country), our problem is how to secure the borders because there are many channels through which it could come into the market,” she said.

The government must be able to prevent the entry of counterfeit drugs into the country, Calimag said.

The PPA and PMA are members of Samahan Laban sa Pekeng Gamot.

It has been estimated that one of every 10 drugs in the country is fake, based on the cases reported to the FDA.

The country’s pharmaceutical market is steadily growing, making it a target of counterfeiters.

In its website, Samahan has identified Binondo, Manila as among the hotspots for counterfeit medicine.

The funny part is, I actually AGREE with most of what is said in the article.

Yes, there are tons of smuggled Chinese medicine products of questionable integrity.  I am the FIRST to admit that probably half of all over the counter drugs sold in Chinese drugstores are of poor quality or fake.

But in NO WAY should that merit a headline that passes judgment on the Chinese medical tradition as a whole!

Now for the one part of the article I don’t agree with: the idea that if a Chinese materia medica does not pass through the FDA, it should not be used at all.

Hence, let’s ban drinking tea for health purposes.

Let’s ban the use of ginger tea or salabat to relieve sore throat.

Let’s ban the use of eating watermelon to keep cool.

Why? Because those are all examples of using materials in the Chinese tradition, as per my previous post.

Shall I go on?  Let’s not use tawas or alum to relieve body odor.  That’s a materia medica used in Chinese medicine, to relieve Heat which manifests as body odor.

Let’s not massage using ginger oils for body aches, let’s ban medicinal massage, let’s ban…

You get the idea.

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The Art of Chinese Medicine

November 15th, 2010 No comments

The past month has been brutal, scheduling wise.  I shan’t bore my handful of readers with the details of the non-essentials.  One of the things keeping me busy though, is having a 4th year medical student rotate with me in Traditional and Integrative Medicine.  For a whole month, I have a future M.D. to “convert” to Chinese medicine heh heh.

Anyway, during one of our rounds, she mentions to me that the subject of Chinese herbal medicine was brought up during her rounds with another doctor.  This other doctor encouraged her to study Philippine herbs instead of Chinese herbs because obviously, using indigenous resources is more cost-efficient than importing from China.  Also, indigenous materia medica would also be more apt and appropriate for the environment in which it grows.  Ma Huang works well in northern China for example, but not in tropical Philippines.

This got me thinking.  Just what IS the essence of Chinese medicine?  When I talk to most westerners about Chinese materia medica, most people think of stuff like Ginseng or Cordyceps.  In other words, they think about the individual materials.  Some folks with more experience might think of individual formulas – I know of a local nephrologist who actually tells patients with stones to take an over the counter stone “melting” formula from China with much success.

But is that what Chinese medicine is?  The individual materia medica?  The Formulae?

No.

The World Health Organization defines traditional medicine as “the sum total of knowledge, skills and practices based on the theories, beliefs and experiences indigenous to different cultures that are used to maintain health, as well as to prevent, diagnose, improve or treat physical and mental illnesses.”  If used outside it’s indigenous culture, it is termed alternative or complementary medicine.  (http://www.who.int/mediacentre/factsheets/fs134/en/).

Hence, the idea of medicine is not the drugs, not the acupuncture, not the materia medica.  I’ve even given this example to medical students – if for example, a person takes a certain common antibiotic but uses it for “off-label” purposes (as is rampant in the Philippines), is that person practicing medicine?  Sure, that person is using a medical tool, but not based on the knowledge, skill, and practice on which the art of medicine is based.

Chinese medicine, it can be imputed, is not about the individual materia medica.  It is about the unique theory that the practice is based on.  In particular, Chinese herbal medicine is not about the individual materia, it is about how they are used and the framework in which they are used.

Ephedra has it’s specific indications in Chinese Medicine.  Weight loss is not one of them.  Therefore, using ephedra in weight loss  - even if the ephedra is a commonly used Chinese materia medica – is not practicing Chinese medicine.

American Ginseng is grown in Wisconsin in the United States.  Frankincense and Myrrh are more associated with the Middle than the Far East.  Yet all are used in Chinese herbal medicine so long as they can be made to fit within the tradition.

So how do I reconcile my student’s story with this?

Philippine herbs can be studied and classified according to the system of Four Natures and Five Tastes.  Once this is done, it is a matter of substituting appropriate local medicinals for the imported ones, but STILL WITHIN THE FRAMEWORK OF CHINESE MEDICAL THEORY.  Let’s take a formula – Dang Gui Bu Xue Tang – with two ingredients Dang Gui and Huang Qi.  What if we can find two local materials that can be used to replace either one (with dose adjustments of course).  We could help more people at less cost.

That would be a true integration of cultures.

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Mainstream Medical Journals say Acupuncture Works; Skeptics Irritated.

September 5th, 2010 1 comment

I’m a bit tired so I’ll just quote this article and comment on it:

Outrage over Acupuncture Evidence Attacks NIH (http://www.healthcmi.com/index.php/acupuncturist-news-online/291-outrageacupunctureproofnih)

Doctors from the University of Maryland School of Medicine, Baltimore and the University of Vermont College of Medicine, Burlington published a case vignette in the New England Journal of Medicine recommending acupuncture for the treatment of lower back pain. The article cites that patients with lower back pain account for over $90 billion in annual health care expenses in the US. The doctors conclude that acupuncture is an effective means for treating lower back pain based partly on a recent study of 6,359 patients published in Spine1. For the lower back pain patient in the case study presented, 10-12 acupuncture treatments over an 8 week period are recommended.

Hmmm, why do these names sound familiar?  Oh I recall!  I had cited the University of Maryland Medical Center for it’s excellent website resource on astragalus root (Huang qi) research.  (http://qi-spot.com/2009/10/20/astragalus-root-for-swine-flu/).   Apparently, those guys are quite open minded.

So anyway, what this means is that some doctors published their opinions that acupuncture should be recommended.  Fair enough.  Everyone’s entitled to an opinion, right?  If it’s wrong, let it be proven wrong through tact and reasoning.

NOT.

The pro-acu docs cite extensive evidence:

The doctors cite physiological phenomena that measure the effects of acupuncture. Local anesthesia at needle insertion sites block the the analgesic effects of acupuncture showing that acupuncture is dependent upon neural innervation2. Acupuncture has been proven to cause the release of endogenous opioids in brain-stem, subcortical, and limbic structures3,4. Acupuncture has also been proven to induce the secretion of adrenocorticotropic hormone and cortisol from the pituitary gland thereby creating a systemic anti-inflammatory response5. Functional MRI studies in humans reveal that acupuncture stimulates limbic and basal forebrain areas involved in pain processing6. PET scan MRIs (positron-emission tomography) show that acupuncture increases opioid binding potential in the brain for several days7. Acupuncture has also been proven to mechanically stimulate connective tissues8, release adenosine at the site of needle stimulation9, and increase local blood blow10. The doctors then cite clinical trials showing the efficaciousness of acupuncture in the treatment of thousands of patients10-15.

So what do some skeptics do?  Do they try to base their argument on refuting the evidence?

Despite this overwhelming evidence proving the mechanisms of action and efficaciousness of acupuncture, skeptics were outraged at the publication of an article supportive of acupuncture in the venerable New England Journal of Medicine. An article recently posted in the Forbes “science business” section stated that the article is “embarrassing” and that acupuncture “infiltrates” the University of Maryland Medical School. In the article, the author calls acupuncture “pseudoscience” and states that it is based on “magical thinking of non-existent life-force.” The skeptic author’s only proof of his theory is that one of the many studies cited in the article found that acupuncture was only 47.6% effective for the treatment of lower back pain and that sham acupuncture was 44.2% effective. Therefore, the author concludes that using “toothpicks” randomly on the human body will have the same pain relieving effects as acupuncture. What the author fails to mention in the Forbes attack article is that conventional western medicine therapy (a combination of drugs, physical therapy, and exercise) was only 27.4% effective in that very same study. Should we therefore abolish western medicine by MDs and call it pseudoscience? Acupuncturists have noted that the success of sham acupuncture noted in that particular study of 1,162 patients in Germany reveals that poorly placed acupuncture needles also derive benefit for the patient.

I have already blogged at length on the physiologic differences between sham and real acupuncture (http://qi-spot.com/2010/04/30/definite-proof-acupuncture-more-than-placebo/) and why it SEEMS that acupuncture is hard to validate using holy grail of western medicine studies – the double blind study (http://qi-spot.com/2010/03/30/how-to-research-acupuncture/).

What I also find interesting is the insistence of skeptics that acupuncture works by balancing Qi or something.  That is the lynchpin of their argument.  I can hear it now:

Skeptic: “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”There are modern, scientifically proven phenomena that explains what we mean by qi flow.  The “needling sensation” is a result of stimulation of nerve fibers, and can be inhibited by certain drugs.  Qi can also be used to mean function, so when “qi” is deficient, one can say there may be decreased circulation to a certain area, or decreased organ function.  An excess of qi can mean a muscle is too tense… (cites more examples)”

Skeptic: (oblivious) “They believe in some quasi mystical energy flow!  That means acupuncture MUST be quackery!”

Acupuncturist:  ”Never mind.”

Seriously, I feel that way sometimes, talking to skeptics.  What’s the point?  You can treat pain in these people and they’ll assign all sorts of reasons EXCEPT the obvious – acupuncture works.

The use of the word “toothpick” also indicates a lack of even a basic awareness of how acupuncture is performed.  You don’t just “prick” people, you insert the needle and manipulate it.

Oh well…

And lastly, a list of references cited by the link I cited…

References

1. Yuan J, Purepong N, Kerr DP, Park J, Bradbury I, McDonough S. Effectiveness of acupuncture for low back pain: a systematic review. Spine 2008;33:E887-E900.

2. Wang SM, Kain ZN, White P. Acupuncture analgesia: I. The scientific basis. Anesth Analg 2008;106:602-10.

3. Han JS. Acupuncture: neuropeptide release produced by electrical stimulation of different frequencies. Trends Neurosci 2003;26:17-22.

4. Pomeranz B. Scientific research into acupuncture for the relief of pain. J Altern Complement Med 1996;2:53-60.

5. Li A, Lao L, Wang Y, et al. Electroacupuncture activates corticotrophin-releasing hormone-containing neurons in the paraventricular nucleus of the hypothalamus to alleviate edema in a rat model of inflammation. BMC Complement Altern Med 2008;8:20.

6. Dhond RP, Kettner N, Napadow V. Neuroimaging acupuncture effects in the human brain. J Altern Complement Med 2007;13:603-16.

7. Harris RE, Zubieta JK, Scott DJ, Napa- dow V, Gracely RH, Clauw DJ. Traditional Chinese acupuncture and placebo (sham) acupuncture are differentiated by their effects on mu-opioid receptors (MORs). Neuroimage 2009;47:1077-85.

8. Langevin HM, Churchill DL, Wu J, et al. Evidence of connective tissue involvement in acupuncture. FASEB J 2002;16:872-4.

9. Goldman N, Chen M, Fujita T, et al. Adenosine A1 receptors mediate local anti-nociceptive effects of acupuncture. Nat Neurosci 2010 May 30 (Epub ahead of print).

10. Sandberg M, Lundeberg T, Lindberg LG, Gerdle B. Effects of acupuncture on skin and muscle blood flow in healthy subjects. Eur J Appl Physiol 2003;90:114-9.

11. Brinkhaus B, Witt CM, Jena S, et al. Acupuncture in patients with chronic low back pain: a randomized controlled trial. Arch Intern Med 2006;166:450-7.

12. Haake M, Muller HH, Schade-Brittinger C, et al. German Acupuncture Trials (GERAC) for chronic low back pain: randomized, multicenter, blinded, paralel-group trial with 3 groups. Arch Intern Med 2007;167:1892-8. [Erratum, Arch In- tern Med 2007;167:2072.]

13. Cherkin DC, Sherman KJ, Avins AL, et al. A randomized trial comparing acupuncture, simulated acupuncture, and usual care for chronic low back pain. Arch In- tern Med 2009;169:858-66.

14. Thomas KJ, MacPherson H, Thorpe L, et al. Randomised controlled trial of a short course of traditional acupuncture compared with usual care for persistent non-specific low back pain. BMJ 2006; 333:623. 15. Witt CM, Jena S, Selim D, et al. Prag- matic randomized trial evaluating the clinical and economic effectiveness of acupuncture for chronic low back pain. Am J Epidemiol 2006;164:487-96.

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