THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY MEDICINEVolume .docx

THE JOURNAL OF ALTERNATIVE AND COMPLEMENTARY
MEDICINE
Volume 9, Number 4, 2003, pp. 479–490
© Mary Ann Liebert, Inc.
The Use of Electro-Acupuncture in Conjunction with
Exercise for the Treatment of Chronic Low-Back Pain
CECILIA K.N. YEUNG, M.Sc.,1,2 MASON C.P. LEUNG,
Ph.D.,1
and DANIEL H.K. CHOW, Ph.D.3
ABSTRACT
Objectives: To determine the effect of a series of electro-
acupuncture (EA) treatment in con-
junction with exercise on the pain, disability, and functional
improvement scores of patients with
chronic low-back pain (LBP).
Design: A blinded prospective randomized controlled study.
Subjects and interventions: A total of 52 patients were randomly
allocated to an exercise
group (n � 26) or an exercise plus EA group (n � 26) and
treated for 12 sessions.
Outcome measures: Numerical Rating Scale (NRS), Aberdeen
LBP scale, lumbar spinal active
range of movement (AROM), and the isokinetic strength were
assessed by a blinded observer.
Repeated measures analysis of variance (R-ANOVA) with

factors of group and time was used
to compare the outcomes between the two groups at baseline
(before treatment), immediately
after treatment, 1-month follow-up, and 3-month follow-up. The
level of significance was set at
p � 0.05.
Results: Significantly better scores in the NRS and Aberdeen
LBP scale were found in the ex-
ercise plus EA group immediately after treatment and at 1-
month follow-up. Higher scores were
also seen at 3-month follow-up. No significant differences were
observed in spinal AROM and
isokinetic trunk concentric strength between the two groups at
any stage of follow-up.
Conclusions: This study provides additional data on the
potential role of EA in the treatment
of LBP, and indicates that the combination of EA and back
exercise might be an effective option
in the treatment of pain and disability associated with chronic
LBP.
479
INTRODUCTION
Low-back pain (LBP) is a major health andeconomic problem in
Western countries
(van Tulder et al., 1997). At any given time,
some 31 million people in the United States
have low-back pain (LBP; Jensen et al., 1994),
and one half of the working population in the
United States have back symptoms each year
(Vallfors, 1985). Other studies have put the an-

nual incidence in the United States as high as
70% (National Institute for Occupational Safety
and Health, 1997). In a local survey, 39% of
adults in Hong Kong reported that they had
had at least one episode of LBP since birth (Lau
et al., 1995), and a telephone survey reported
that the cumulative life prevalence and the 12-
month prevalence of LBP in the Hong Kong
1Department of Rehabilitation Sciences, The Hong Kong
Polytechnic University, Hung Hom, Hong Kong.
2Physiotherapy Department, the Kwong Wah Hospital, Hong
Kong.
3Jockey Club Rehabilitation Engineering Center, The Hong
Kong Polytechnic University, Hung Hom, Hong Kong.
population were 57% and 42%, respectively
(Leung et al., 1999). Although there are no doc-
umented figures on the number of days sick
leave and compensation costs related to LBP in
Hong Kong, 66.8% of LBP subjects reported
that their back pain was work-related (Leung
et al., 1999).
The effectiveness of therapeutic interven-
tions for the treatment of chronic LBP has not
been convincingly demonstrated (Frymoyer,
1988; Spitzer et al., 1987). Acupuncture is an-
ticipated as being a potentially useful treatment
strategy to complement traditional Western
medical management in alleviating the pain
and disability associated with chronic LBP.
There has been an increasing use of acupunc-
ture in pain management (Woollam and Jack-

son, 1998), and acupuncture is now available
as a treatment option in chronic pain clinics in
many countries (Woollam and Jackson, 1998).
Electro-acupuncture (EA) is based on conven-
tional acupuncture, with the additional appli-
cation of an electric pulse to meridians and
acupoints in order to strengthen the effect. This
method is generally used for analgesia and has
become increasingly popular since the 1970s
(Chan, 1974; Tsui et al., 2002). This modality of
acupuncture has the advantages of standard-
ized quantity and quality of stimulation by con-
trolling the input current amplitude and fre-
quency.
The reported efficacy of acupuncture for the
management of chronic LBP in randomized
controlled trials was reviewed (van Tulder et
al., 1997) and it was found that the hetero-
geneity and poor methodological quality of the
studies conducted made the validity of results
obtained less convincing than they initially ap-
peared. Although evidence of long-term pain
relief after manual acupuncture and EA in
chronic nociceptive (nonorganic) LBP com-
pared to placebo was demonstrated (Carlsson
et al., 2001), the effectiveness of EA in treatment
of other forms of chronic LBP remains unclear.
The effects of acupuncture and acupuncture
plus back exercise have been compared (Song,
1993). However, the outcome measure was not
properly controlled because the therapeutic ef-
fect was rated subjectively as cured, markedly
effective, improved, and ineffective according
to the degree of alleviation of sign and symp-

tom (Song, 1993). Therefore, a well-designed
randomized control trial with a larger sample
size, valid acupuncture treatment, and out-
come measures is needed to determine the ef-
fectiveness of EA in the management of chronic
LBP. For ethical reasons, it was not feasible to
include an untreated control in this study, and
back exercise is used as is typically adminis-
tered by physiotherapists, either alone or in
combination with other methods of treatment
for chronic LBP. No attempt is made to com-
pare the efficacy of EA to more active ap-
proaches to treating chronic LBP patients (Kose
et al., 1995; Torstensen et al., 1998). Conse-
quently, the present randomized, assessor-
blinded controlled clinical trial is designed to
investigate the immediate and medium-term
effects of back exercises alone (control group)
or in conjunction with a series of EA treatment
(experimental group) on the pain, disability
and functional scores in patients with chronic
LBP.
MATERIALS AND METHODS
Patients with chronic LBP satisfying the in-
clusion and exclusion criteria listed in Table 1
were recruited through referral from the med-
ical officer in charge of the outpatient clinic of
the Department of Orthopaedics and Trauma-
tology, Kwong Wah Hospital, Hong Kong, dur-
ing the period 2001–2002. As a detailed specific
Western diagnosis cannot be made in the ma-
jority of patients with chronic LBP (Deyo and
Phillips, 1996; Waddell et al., 1996), subjects in-
cluded in this study were those with nonspe-

cific back pain without any underlying patho-
physiologic or anatomic problems identified
during physical and radiologic examination
(Hadler, 1993). Inclusion, exclusion, and with-
drawal criteria are listed in Table 1. Patients ful-
filling these criteria were asked to participate
in the study, and the aims and procedure of the
study were explained before written consent
was obtained. Ethical approval from the Ethics
Committee of the Hong Kong Hospital Au-
thority and the Human Subject Ethics Sub-
committee of The Hong Kong Polytechnic Uni-
versity was obtained prior to the start of the
study. Blocked randomization of patients to ei-
YEUNG ET AL.480
ther the exercise group (n � 26) or the exercise
plus EA group (n � 26) was used in this study
to minimize possible selection bias. Allocation
of patients to the two groups was randomized
and blinded, and patients were asked not to un-
dergo any other types of therapy for LBP dur-
ing the study period to avoid contamination of
the results.
Treatment procedure
Back exercise group. Patients received physio-
therapy in the form of a standard group exer-
cise program led by the same physiotherapist.
The program consisted of an hourly session
each week for 4 consecutive weeks, and com-
prised the following back strengthening and

stretching exercises:
• Warm up and stretching of back muscles �
10 minutes;
• Back extension exercise � 15 repetitions � 3
times with rest between (progress with
adding arm weight);
• Abdominal exercise � 15 repetitions � 3
times with rest between (progress by repo-
sitioning the arms); and
• Cool down with stretching of back muscles �
10 minutes.
In addition, patients were advised on spinal
anatomy and body mechanics, back care and
postural correction, lifting and ergonomic ad-
vice, and behavioral modification, as well as a
series of home exercises (15 minutes per day).
Patients were instructed to perform the desig-
nated types of back exercise every day over the
period of the study. Home exercise monitoring
cards were given to patients for recording pur-
poses, and an independent assessor checked
the patient’s compliance using these cards.
Back exercise plus EA group. The group exer-
cise program was conducted by a blinded ther-
apist in the same way as for the exercise group.
In addition, EA was administered three times
per week for 4 weeks by another physiothera-
pist certificated in acupuncture. The acupoints
were chosen according to a summation of com-

mon points used in the literature reviewed
along the Bladder and Spleen meridian (Coan
et al., 1980; Edelist et al., 1976; Gunn et al., 1980;
Lehmann et al., 1986; MacDonald et al., 1983;
Thomas et al., 1994). These were the UB23
(Shenshu), UB25 (Dachangshu), UB40 (Weiz-
hong), and SP 6 (Sanyinjiao) points (Fig. 1).
Acupuncture was applied to the side on which
patients reported pain. If the reported pain was
bilateral, EA was applied to the more painful
side. The patient was placed in a prone posi-
tion and a sterilized disposable number 30 (0.3-
mm diameter) 40-mm long needle was inserted
and manipulated until a sensation of numb-
ELECTRO-ACUPUNCTURE ON CHRONIC LOW-BACK PAIN
481
TABLE 1. INCLUSION, EXCLUSION AND WITHDRAWAL
CRITERIA
Inclusion criteria
1. Chronic LBP
It was defined as a complaint of pain of the lower back below
the
12th thoracic vertebrae with or without radiation with an onset
of
duration of 6 months or more
2. Age between 18–75 and of both genders
Exclusion criteria
1. Structural deformity (ankylosing spondylitis, scoliosis)
2. Lower limb fracture
3. Tumors

4. Spinal infection
5. Cauda equina syndrome
6. Pregnancy
7. Spinal cord compression
8. Subjects who were inability to keep the appointments
9. Receiving acupuncture treatment within the past 6 months
10. Receiving physiotherapy treatment within the past 3 months
Withdrawal criteria
1. Other acute orthopaedic or medical problems that hinder back
exercise
LBP, lower back pain.
ness, tingling, heat, or distension at the site of
needle insertion, known as te chi in Chinese
Traditional Medicine, was obtained. The nee-
dle was then coupled to an electrical stimula-
tor (Shanghai Medical Technology Co., Shang-
hai) at a frequency of 2 Hz as suggested by
Han et al. (1981) for 30 minutes to allow en-
dorphinergic analgesia to build up (Gabriel et
al., 1985). The intensity of the stimulation was
set at the level that the patient could tolerate
and often with evoked visible muscle con-
tractions. We applied the current with bipha-
sic waveform (positive wave in the square
form and negative wave in the triangle form
with 0.5-ms pulse width) to the four selected
acupoints in two pairs (i.e., UB-23/UB-25 pair
and UB40/SP6 pair).
Collected data and outcome measures. All pa-

tients were assessed by a blinded observer who
was not aware of the treatment allocation. The
assessment was performed before and after the
treatment series as well as at 1 and 3 months
after the treatment. In this study, the primary
outcome measures were:
(1) Pain—Numerical rating scale (NRS) was
used to measure the average and the worst
pain intensity during the last week on as-
sessment, by asking the patient to rate his
or her perceived level of pain intensity on
a numerical scale from 0 to 10, with 0 rep-
resenting one extreme (no pain) and 10 rep-
resenting other extreme (pain as bad as it
could be). This shows a high reliability in
both literate and illiterate patients (Ferraz
et al., 1990), and it has also been demon-
strated that the NRS and visual analog
scales (VAS) have correlation ranging from
r � 0.77 to 0.91 (Downie et al., 1978).
(2) Disability—The Aberdeen LBP scale was
used to measure low back disability, be-
cause it is the only LBP-specific functional
disability scale that has been validated for
use in Chinese subjects. It consists of a 19-
item questionnaire that has been adapted
to be appropriate for Chinese culture, and
has a reported test-retest reliability of r �
0.94 (p � 0.05) with Cronbach � equal to
0.85. The correlation with the current
generic 42-item questionnaire is 0.59. It as-
sesses the health status of patients with LBP
across several dimensions, including pain,

physical impairments, and functional dis-
ability. Responses to the questions were
summed and converted to a score percent-
age between 0 and 100, with 0 representing
the least disabled and 100 the most severely
disabled (Leung et al., 1999).
Secondary outcome measures used in this
study were:
(1) Lumbar spinal angular range of motion (ROM)
in flexion-extension—The angular ROM of
the lumbar spine was measured using a
Dualer Plus inclinometer (Jtech Medical In-
dustries, Salt Lake City, UT). A pilot study
showed the inclinometer to give reliable
measurements, with intraclass correlation
coefficients (ICC) model (1,1) of 0.90 for
trunk flexion and 0.80 for extension. The
device was secured to the patient at the
sacrum and the thoracolumbar junction.
YEUNG ET AL.482
FIG. 1. The four acupoints, UB-23 (Shenshu), UB25
(Dachangshu), UB-40 (Weizhong), and SP-6 (Sanyinjiao),
used in the study.
Each exercise was demonstrated by the in-
vestigator and then practiced by the pa-
tients. Two trials of flexion-extension were
then carried out. The highest value gener-
ated was taken as representative for that
movement.

(2) The isokinetic trunk flexor and extensor
strength—The isokinetic trunk flexor and
extensor strength were measured using a
Cybex 6000TEF modular component isoki-
netic dynamometer (Lumex, Inc.,
Ronkonkoma, NY). Patients were mea-
sured standing with positioning standard-
ized according to the manufacturer’s rec-
ommendations. The axis of rotation was
centered approximately at the intersection
of the mid-axillary line and L5-S1, and the
angular ROM was set at 5-degree extension
and 60-degree flexion in all patients. Mea-
surements were at an angular velocity of 60
degrees per second because this closely ap-
proximates to a number of daily activities
(Motulsky, 1995). Five trial repetitions pre-
ceded measurements, where the same ex-
aminer asked the patient to move or pull
“as hard and as fast as they could.” Flexor
peak torque percent body weight (FPTBW),
extensor peak torque percent body weight
(EPTBW), flexor total work percent body
weight (FTWBW), and extensor total work
percent body weight (ETWBW) at 60° per
second were then measured over the fol-
lowing five repetitions.
Follow-up. Assessment was performed before
(as baseline) and immediately after the treat-
ment series. Follow-up assessment was at 1 and
3 months after the treatment series. The pa-
tients were reminded by either telephone or
mail. Exercise level, analgesic consumption,
and whether they had undertaken any other

therapy for their LBP during the study were
recorded, and all patients were also given a de-
tailed self-administered questionnaire on their
demographic information.
Statistical methods. Statistical analysis was
conducted based on the intention-to-treat prin-
ciple. Patients dropping out for reasons other
than the treatment to which they had been ran-
domly assigned were given the baseline regis-
tration scores for the missing timepoints. Pa-
tients dropping out because of the treatment to
which they were randomly assigned were
given the worst score registration (Torstensen
et al., 1998). To determine the robustness of
conclusions, the analysis was repeated when
missing data were discarded (Motulsky, 1995).
The former analysis (intention to treat) may
make it harder to find significant differences,
while the latter analysis (discarding missing
data) may make it easier to find significant dif-
ferences. Comparison of the demographic
characteristics and other variables of the two
groups at baseline were using the �2 test and t
test according to whether the variables under
consideration were categorical or continuous,
respectively. The mean was used as an index
of localization, and standard deviation as index
of dispersion. Changes in NRS, Aberdeen LBP
scale, spinal angular ROM in flexion-extension
and reciprocal isokinetic trunk concentric
flexor and extensor strength for the two groups
immediately after the treatment series, at 1-
month follow up and at 3-month follow up
were assessed using a two-factor (group �

483
FIG. 2. Flow diagram describing the patients during the
study period. OPD, outpatient department; EA, electro-
acupuncture.
time of assessment) mixed repeated measures
analysis of variance (R-ANOVA). Differences
in the response over time between the two
groups were indicated by a significant interac-
tion. The level of significance was set at p �
0.05 in all comparisons. Analyses were per-
formed using SPSS for Windows statistical soft-
ware (version 10.0, SPSS, Inc., Chicago, IL).
RESULTS
Fifty-two (52) patients were entered to the
study over a period of 12 months. None of them
had undergone any back surgery before, and
all subjects completed the treatment sessions.
Three patients dropped out during the follow-
up period. Two were in the back exercise group
and defaulted at post-1–month follow-up be-
cause of lack of time to come for reassessment,
and one patient in the back exercise plus EA
group suffered from stroke before 3-month fol-
low-up (Fig. 2).
Sociodemographic characteristics

Admission data for the patients are summa-
rized in Table 2. There were no statistically sig-
nificant differences between the two groups in
terms of age, gender, body height, body
weight, duration of symptoms, diagnosis,
symptom radiation, and other treatment pro-
YEUNG ET AL.484
TABLE 2. BASELINE CHARACTERISTIC OF THE SUBJECTS
p value (group
Baseline characteristics n % n % difference)
Age (mean; SD) 55.6; 10.4 years 50.4; 16.3 years 0.177a
Body height (mean; SD) 155.8; 7.0 cm 155.5; 7.8 cm 0.867a
Body weight (mean; SD) 59.1; 7.96 kg 61.72; 10.78 kg 0.324a
Gender
Male 5 19.2% 4 15.4% 0.714b
Female 21 80.8% 22 84.6%
Duration of symptoms
6 month 4 15.4% 2 7.7% 0.665b
7–12 months 2 7.7% 5 19.2%
13–18 months 2 7.7% 3 11.5%
19–24 months 3 11.5% 2 7.7%
� 25 months 15 57.7% 14 53.8%
Presence of prolapsed
intervertebral disc
No 23 88% 26 100.%
Yes 3 12% 0 0.% 0.074b
Radiation
No 12 46.2% 12 46.2%

Yes 14 53.8% 14 53.8% 1.00b
Analgesic consumption
No 26 100.% 25 96.2%
Yes 0 0.% 1 3.8% 0.313b
Exercise level
No 10 26.9% 7 38.5%
Yes 16 73.1% 19 61.5% 0.375b
Receive other forms of treatment
No 20 76.9% 21 80.8%
Yes 6 23.1% 5 19.2% 0.734b
aIndependent T test.
b�2 test.
Radiation: complain of pain below the buttock level.
Analgesic consumption: no (not taken any analgesic); Yes
(taken analgesic regularly or when necessary).
Exercise level: no (not perform exercise once per week); yes
(perform exercise at least once per week).
Other forms of treatment: including Tui Na, massage,
chiropactor, bone setter, using corset, or other treatment on
the back.
EA, electro-acupuncture; SD, standard deviation.
Exercise group
(n � 26)
Exercise plus EA
group (n � 26)
grams prior to intervention. Blinded assess-

ment showed that compliance with the back
exercise program was equally good in both
groups. No patient received any other type of
therapy for back pain during the study period,
and all patients tolerated EA well without ad-
verse effects.
Outcomes
There were no significant differences be-
tween two groups with respect to analgesic
consumption and exercise level before, post-
treatment, post-1–month and 3-month follow
up (Table 3). Although there were no statisti-
cally significant differences between the two
groups at baseline, factors such as analgesic
consumption and the presence of prolapsed in-
tervertebral disc could confound the results,
and outcomes were analyzed while controlling
these two factors as covariates.
(1) Pain—On the NRS average pain score mea-
sure, interaction between group and time
of analysis was significant (p � 0.001). Sep-
arate analysis of covariance (ANCOVA)
was therefore performed to detect the dif-
ference between groups at any given time.
The mean score was lower in the exercise
plus EA group compared with the exercise
group alone. There was a significant re-
duction in the average pain score between
baseline and each of the follow-up assess-
ments such as post-treatment (p � 0.032, 1-
month follow-up (p � 0.030), and 3-month
follow-up (p � 0.005) (Table 4).

For the worst pain score, interaction be-
tween group and time of analysis was sig-
nificant (p � 0.005). Separate ANCOVA was
performed to detect the difference between
groups at any given time. The mean score
was lower in the exercise plus EA group as
compared with the exercise group alone.
There was a significant reduction in the
worst pain score at post-treatment (p �
0.026), to 1-month follow-up (p � 0.018) and
3-month follow-up (p � 0.001) (Table 4).
(2) Disability—On the Aberdeen LBP scale, in-
teraction between group and time of analy-
sis was significant (p � 0.001). Separate
ANCOVA was therefore performed to ex-
amine the difference between groups at any
given time. The mean score was lower in
the exercise plus EA group compared to the
exercise group alone. There was a signifi-
cant reduction in the Aberdeen LBP scale
post-treatment (p � 0.002), to 1-month fol-
low-up (p � 0.003), and 3-month follow-up
(p � 0.001) (Table 4).
(3) Isokinetic muscle strength—For the EPTBW
60° per second, the mean score was higher
in the exercise plus EA group compared to
exercise group alone at post-treatment to
1-month follow-up and 3-month follow-up,
however, it was not significant (p � 0.20).
It only demonstrated a significant differ-
ence between the various time periods

485
TABLE 3. ANALGESIC CONSUMPTION AND REGULAR
EXERCISE PERFORMED BEFORE, POST-TREATMENT,
POST-ONE–MONTH FOLLOW-UP AND POST-THREE–
MONTHS FOLLOW-UP
Exercise plus EA p value
Exercise group group (group
n � 26 n � 26 difference)
Analgesic consumption
No/Yes Pre 26/0 25/1 0.313
Post 24/2 20/6 0.124
Post-1–month 24/2 23/4 0.385
Post-3–months 22/4 24/2 0.385
Exercise level
No/Yes Pre 10/16 7/19 0.375
Post 8/18 3/23 0.090
Post-1–month 7/19 3/23 0.159
Post-3–months 7/19 3/23 0.159
�2 test used.
EA, electro-acupuncture.
within the subject group (p � 0.000)
(Table 4).
For the FPTBW 60° per second, the mean
score was higher in the exercise plus EA

group compared to the exercise group
alone at post-treatment to 1-month follow-
up and 3-month follow-up. It only demon-
strated a significant difference between the
various time periods within the subject
group (p � 0.000) but no significant differ-
ence was found between the two groups
(p � 0.454) (Table 3).
For the ETWBW 60 degrees per second,
the mean score was higher in the exercise
plus EA group compared to exercise group
alone at post-treatment to 1-month follow-
up and 3-month follow-up. No significant
differences within (p � 0.119) and between
the two groups (p � 0.125) was found at
any of the follow up periods (Table 4).
For the FTWBW 60 degrees per second,
the mean score was higher in the exercise
plus EA group compared to exercise group
alone at post-treatment to 1-month and 3-
YEUNG ET AL.486
TABLE 4. CHANGES IN PAIN, DISABILITY, SPINAL AROM,
AND ISOKINETIC MUSCLE STRENGTH, BEFORE,
POST-TREATMENT, POST-ONE–MONTH FOLLOW-UP AND
POST-THREE–MONTH FOLLOW-UP
Exercise plus EA p value
Exercise group group (excluding
mean (SD) mean (SD) missing
Outcome variables Duration n � 26 n � 26 p value Power data)

NRS Pre 5.88 (1.84) 6.38 (1.77) 0.323 69% 0.179
(average pain score Post 5.12 (2.18) 3.81 (2.10) 0.032* 0.050*
(0–10) Post-1–month 5.19 (2.47) 3.77 (2.12) 0.030* 0.077*
Post-3–month 5.27 (2.31) 3.46 (2.18) 0.005* 0.018*
NRS Pre 6.50 (1.56) 6.65 (1.77) 0.740 80% 0.516
(worst pain score) Post 5.35 (2.04) 3.92 (2.43) 0.026* 0.049*
(0–10) Post-1–month 5.42 (2.45) 3.85 (2.17) 0.018* 0.046*
Post-3–month 5.65 (2.53) 3.46 (2.18) 0.001* 0.004*
Aberdeen LBP scale Pre 32.49 (13.79) 35.32 (11.72) 0.429 89%
0.217
(0 � 100 points) Post 30.82 (13.03) 20.02 (10.47) 0.002*
0.005*
Post-1–month 32.48 (15.31) 20.36 (13.06) 0.003* 0.006*
Post-3–month 25.82 (13.11) 19.86 (10.12) 0.001* 0.001*
Spinal AROM in Pre 45.19 (16.02) 45.69 (22.81) 0.099 38%
0.140
flexion (degree) Post 44.92 (15.14) 55.31 (24.08)
Post-1–month 43.46 (14.29) 50.42 (20.24)
Post-3–month 36.96 (14.31) 44.38 (13.90)
Spinal AROM in Pre 13.23 (7.62) 13.12 (7.40) 0.098 38% 0.066
extension (degree) Post 13.31 (6.83) 16.42 (7.67)
Post-1–month 12.58 (6.88) 14.88 (5.72)
Post-3–month 9.77 (6.45) 12.77 (4.90)
EPTBW 60 degree/ Pre 77.38 (50.20) 89.46 (55.28) 0.200 25%
0.263
sec (nm) Post 89.62 (57.77) 119.27 (47.84)

Post-1–month 101.88 (80.06) 134.08 (84.28)
Post-3–month 108.46 (95.35) 143.85 (74.93)
FPTBW 60 degree/ Pre 127.19 (79.16) 127.42 (63.28) 0.454
11% 0.663
sec (nm) Post 125.73 (76.81) 156.54 (62.35)
Post-1–month 132.54 (78.67) 165.19 (67.96)
Post-3–month 183.19 (141.69) 212.58 (94.38)
ETWBW 60 degree/ Pre 68.77 (65.44) 92.92 (61.16) 0.125 34%
0.194
sec (J) Post 91.77 (73.47) 121.04 (47.29)
Post-1–month 92.85 (78.61) 129.42 (69.89)
Post-3–month 79.38 (79.15) 136.31 (185.53)
FTWBW 60 degree/ Pre 117.23 (102.70) 138.42 (84.12) 0.204
25% 0.623
sec (J) Post 113.27 (93.15) 161.27 (75.77)
Post-1–month 120.38 (101.26) 169.35 (83.49)
Post-3–month 145.08 (128.93) 179.54 (84.02)
*p � 0.05.
AROM, angular range of motion; EA, electro-acupuncture;
EPTBW, extensor peak-torque percent body weight;
FPTBW, flexor peak torque percent body weight; NRS,
numerical rating scale; LBP, low back pain.
month follow-up. A significant difference
between the various time periods was
found within the subject group (p � 0.008)

but no significant difference between the
two groups was found (p � 0.204) (Table 4).
(4) Spinal angular ROM—For the angular ROM
in flexion and extension, the mean of the
exercise plus EA group was better than the
exercise group alone at post-treatment to 1-
month and 3-month follow-up. A signifi-
cant difference between the various time
periods within the subject group was seen
(flexion: p � 0.001 and extension: p � 0.001)
but no significant difference was found be-
tween the two groups (flexion: p � 0.099
and extension: p � 0.098) (Table 4). The
analyses were repeated when all missing
data were discarded. All conclusions were
essentially identical between two groups,
however, final conclusions were drawn
from the intention-to-treat analysis.
DISCUSSION
The aim of this study is to determine if EA
is an effective and safe treatment option that
can reduce pain, decrease disability, and im-
prove functional capacity of patients with
chronic LBP. No adverse reaction to or com-
plications arising from EA were found in this
study. In this randomized trial, there was a sig-
nificant reduction of pain and disability in the
exercise plus EA group. While the results of
spinal angular ROM and reciprocal isokinetic
trunk measurement showed the mean changes
to be superior in the exercise plus EA group at
all time points, these differences did not reach
statistical significance between the two groups.

These results support the growing body of
literature that there is often little correlation
among actual functional impairment (such as
lumbar motion and muscle strength), disabil-
ity and the self-assessment of pain (Hazard et
al., 1994; Waddell, 1992). All of these physical
measures are affected by patient’s motivation,
effort, and psychological state (Deyo, 1988). It
has been concluded that these measures are
poor at predicting long-term outcome, includ-
ing return to full normal activity (Deyo, 1988).
The results of these studies show that changes
in these outcome measures were not always re-
lated to the changes in patient’s ability to per-
form functional tasks. This demonstrates the
importance of considering the multiplicity of
factors that define the function and disability
indexes of those suffering from chronic LBP.
Because of this, many authors are now ques-
tioning the exclusive use of impairment mea-
sures to determine the outcome treatment
(Deyo et al., 1994; Jette, 1995; Waddell, 1987).
Therefore the impairment outcomes are only
considered as secondary outcomes in the pres-
ent study. The results of angular ROM in the
current study were consistent with the finding
of Edelist et al. (1976). One possible reason for
lack of significant change in angular ROM may
be because of the high baseline values found in
this study, as most of the patients were able to
reach below the knee in flexion and behind the
thigh in extension. Another possible reason for
the lack of significant change was the low
power, ranging from 11% to 38% of these pa-

rameters (Table 4). A larger sample size may
be needed to detect significant changes.
Different outcome measures probably mea-
sure different entities, and therefore to get a
fuller picture of the intervention a combination
of relevant outcome measures should be used
(Delitto, 1994; Deyo et al., 1988; Jette, 1994). The
current study takes this into account by using
the Aberdeen LBP scale to evaluate the pa-
tient’s progress after treatment. This disease-
specific questionnaire is a simple clinical tool
and contained questions adapted for Chinese
subjects, giving a high level of reliability and
validity (Leung et al., 1999). Use of a self-re-
ported disease-specific questionnaire to assess
a patient’s level of function or disability in
chronic LBP has been highly recommended
(Paul and Christopher, 1997). As such, the Ab-
erdeen LBP scale was used in combination with
NRS as the primary outcome measure. Analy-
sis after discarding the missing data or on the
basis of an intention-to-treat analysis did not
result in any significant changes in the results.
Powers ranging from 69% to 89% were ob-
tained for all of the primary outcome measures
(Table 3), indicating a strong confidence in the
short and medium-term pain relieving effect
(NRS) and decrease in disability (Aberdeen
LBP scale) in the exercise plus EA group com-
487

pared to back exercise alone. This outcome has
been suggested by previous literature (Coan et
al., 1980; Lehmann et al., 1986; MacDonald et
al., 1983; Spitzer et al., 1987), but has been lim-
ited by unclear outcome measures and incon-
sistent effects.
The mechanism of EA might be explained by
the findings that EA could accelerate the re-
lease of opioid peptides from the central ner-
vous system (Han and Wang, 1992). An animal
study also showed that repeated EA stimula-
tion has cumulative therapeutic effect on
chronic pain and suggested that EA analgesia
and morphine analgesia share similar mecha-
nism (Wang et al., 1992). Furthermore, Han et
al. (1990) demonstrated that different frequen-
cies of stimulation can facilitate differential re-
lease of different brain neuropeptides.
According to Traditional Chinese Medicine,
chronic LBP is primarily because of deficiency
in the kidney, and the treatment principle is
therefore to reinforce the kidney and strengthen
the bones. Unlike previous studies, which used
a number of acupoints varying between sub-
jects (Coan et al., 1980; Edelist et al., 1976; Gunn
et al., 1980; Lehmann et al., 1986; MacDonald
et al., 1983; Thomas et al., 1994), the current
study only uses four acupoints: UB23 (Shen-
shu), UB25 (Dachangshu), UB40 (Weizhong), and
SP 6 (Sanyinjiao), to reinforce the kidney qi,
dredge the meridians, and activate the collat-
eral (George et al., 1998). The use of these four
acupoints resulted in reduced pain and dis-
ability, and as some patients have a fear of nee-

dle pain, avoiding excessive use of acupoints
may be of benefit.
Limitations
There are a few limitations evident in this
study. Concerns about subjects’ long-term fol-
low-up rate, meant that the follow-up period
of the current study was 3 months after termi-
nation of the treatment series. Therefore, only
the immediate and medium-term effects were
demonstrated, but the long-term benefits of EA
were not examined in this study.
An additional concern regards the lack of
placebo or sham acupuncture control group in
this clinical trial, in that there was no control
for the additional time and attention in the EA
group plus exercise group. It is not known
whether the advantage found for this group is
the result of the EA or to nonspecific treatment
effects associated with these 12 sessions such
as patient expectations or attention from the
therapist. As such, it is impossible to prove
whether EA was an important part of the treat-
ment method or whether the improvement felt
by the patients in the exercise plus EA group
was due to the therapeutic setting and psy-
chological phenomena (Lewith and Machin,
1983; Richardson and Vincent, 1986; Vincent et
al., 1995). However, the interaction between pa-
tient and acupuncturist was minimized to ex-
clude potential bias. No additional intervention
was included, and conversation was limited to
a short explanation about the procedure at each

treatment session. Outcome evaluation was
performed by a blinded assessor and self-re-
ported questionnaire. While it has been argued
that approximately 20%–30% improvement in
short-term pain relief might be expected as a
result of the placebo effect of acupuncture
alone (Richardson et al., 1986), the present
study showed approximately 40% to 45% im-
provement, indicating that EA is likely to
demonstrate some analgesic effect apart from
placebo. Nevertheless, further studies are re-
quired to add weight to the conclusion that EA
has specific therapeutic effect beyond nonspe-
cific placebo effects.
Both groups used a standardized back exer-
cise program, and no studies have been per-
formed to demonstrate the validity and signif-
icance of this program. Because the program
involves both the flexion and extension exer-
cise of the back, the therapist would ask pa-
tients for any increase in pain intensity after
each exercise session to ensure that the exercise
program was not resulting in increased pain
and disability.
CONCLUSIONS
Despite the limitations of this clinical trial,
the randomized clinical trial setting made it
possible to control for cofounders such as age,
gender, duration of pain, and selection bias.
These controls, together with the comparably
homogeneous patient group, blinded random-
YEUNG ET AL.488

ization procedure, standardized treatment and
data collection procedure, low dropout rate
(5.77%), blinded assessment, and data analysis
using the intention-to-treat principle and dis-
carding incomplete data sets all add to the re-
liability of this study. Positive effects of EA
compared to back exercise group alone were
demonstrated in a number of outcome mea-
sures including pain relief and functional ca-
pacities on disability level. This benefit was
maintained at 3-months follow-up. It is con-
cluded that EA has an additional value to stan-
dard back exercise, and may be an effective op-
tion in the treatment of pain and disability
associated with chronic LBP. This study pro-
vides additional data on the potential role of
EA in the treatment of chronic LBP.
Most of the previous studies in EA were lack-
ing in methodological design and consequently
the results produced are less than convincing.
There is an urgent need for further well-
designed clinical trials in this area. A well-
designed, double-blinded, randomized study
with larger sample size and a sham control
group is recommended to examine both the
short- and long-term effects of EA and to pro-
vide more definitive evidence of its effectiveness
or otherwise in the management of chronic LBP.
ACKNOWLEDGMENTS
We acknowledge The Hong Kong Polytechnic

University Area of Strategy Development Fund
(A106) and Tung Wah Board Fund for support-
ing this study. The authors also thank the pa-
tients and staff of the Physiotherapy Department
of the Kwong Wah Hospital, Hong Kong, for
their participation, particularly L. Fung, M.Sc.,
C. Li, M.Sc., S. Cheung, M.Sc., S. Lo, M.Sc., W.
Luk, M.Sc., and R. Wong, M.Sc. We would also
like to express appreciation for Mr. J. Yeung
for his participation in the collection of data and
Andrew Holmes, Ph.D., for the editing.
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E-mail: [email protected]
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