APA in cLBP 2025 – The BMAS Blog
Inspired by Kawi et al 2025.[1]
APA – auricular point acupressure
cLBP – chronic low back pain
IF – impact factor
MSK – musculoskeletal
NRS – numerical rating scale
RMDQ – Roland-Morris Disability Questionnaire– key to acronyms
This is a moderately large 3-arm trial (n=272) from the US. The paper is published in the journal Pain Medicine (IF 2.9), for which I am on the integrative medicine section of the editorial board. I was first invited by Bob Gerwin, who heads the MSK section, but I appear to have migrated to another section since first joining 10 years ago.
I did not remember reviewing this paper, and I was slightly surprised that they did not send it to me, so I checked my records, and found that they did actually send it to me, and I did review it!
The subjects for this study were recruited from metropolitan Baltimore. They were 60 or above and suffered with cLBP of at least 4 on a 0 to 10 NRS. They were randomised to 1 of 3 arms in the study. 2 arms involved APA using 2mm Vaccaria seeds and the third arm was an education control. The latter group was re-randomised to one of the two APA groups following the 1-month follow-up point (see below).
Seeds were placed either at points the authors thought were specific for cLBP or at points that were not considered specific. So, this was a real test of point specificity. The comparison with education, which included attention and interaction of the same duration as in the APA groups, constituted a test of pragmatic effectiveness.
I commented in my review that I would not have used this design. I first wrote about ‘missing the point’ in acupuncture trials nearly 25 years ago.[2]
The treatment schedule was quite efficient. 15-minute sessions were held once a week for 4 weeks. Seeds were placed during these sessions and the patients were asked to apply pressure to the points for 3 minutes 3 times a day for 5 days. On day 5 they (the individual patients) removed the seeds, allowing 2 days for the ears to recover before the next session.
Outcomes were pain NRS and the RMDQ. The pain NRS was rated as the worst pain in the last 7 days. The RMDQ is a 24-item questionnaire scoring 0 to 24 with high scores correlating with greater disability. There were a raft of secondary outcome measures in addition.
Outcomes were measured at baseline, post-treatment (4 weeks), and at 1-, 3-, and 6-month follow-ups. The education control was only measured up to the 1-month follow-up timepoint.
There were absolutely no differences between the two groups with seeds in their ears – those receiving cLBP-specific APA and cLBP-non-specific APA. Both APA groups were significantly better than the education controls at the post-treatment timepoint and at 1 month follow-up.
The results of this paper are entirely in line with predictions based on physiology and lend no support to the concept of somatotopy ie that there is a map of the whole body on each pinna. The authors avoid mentioning the fact that their results provide evidence for the suggestion that there is no such map, instead they go out of their way to explain why the non-specific APA might have worked so well.
Here we are left in the same position as we often are with acupuncture techniques. The research demonstrates effectiveness, but the underlying theoretical basis is not supported. What do we do in these circumstances? Do we carry on teaching elaborate systems and ignore the elephant in the room? Or do we acknowledge the elephant but try to avoid throwing out the baby with the bath water?
Apologies for the muddled metaphors, particularly for readers where English is a second language.
In the BMAS we have moved towards a frank acknowledgement of the elephant and a desperate grasping for any of the potential babies. Time will tell whether or not we caught them.
References
1 Kawi J, Yeh CH, Lukkahatai N, et al. Auricular Point Acupressure for Older Adults with Chronic Low Back Pain: A Randomized Controlled Trial. Pain Med. 2025;pnaf035. doi: 10.1093/pm/pnaf035
2 Cummings M. Commentary: Controls for acupuncture – can we finally see the light? BMJ. 2001;322:1578.
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