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Original paper

The effectiveness of acupuncture for plantar heel


pain: a systematic review
Richard James Clark,1 Maria Tighe2

1
Peninsula College of Medicine Abstract and malignant aetiologies; once such condi-
and Dentistry, Plymouth
University, Plymouth, UK
Introduction Plantar heel pain (PHP) is a common tions are excluded, what remains is PHP.
2
Faculty of Health, Education complaint, yet there are no definitive guidelines for Typical findings include pain on taking the
and Society, School of Nursing its treatment. Acupuncture is increasingly used by first few steps in the morning, pain that
and Midwifery, Plymouth
University, Plymouth, UK
podiatrists, and there is a need for evidence to increases with weight bearing, and pain and
validate this practice. It is acknowledged that PHP tenderness upon palpation of the medial calca-
Correspondence to and acupuncture are both complex phenomena. neal tubercle.5
Dr Richard J Clark, Peninsula
College of Medicine and
Method A systematic review (PROSPERO no. Historically, PHP has been referred to as
Dentistry, C206 Portland CRD42012001881) of the effectiveness of ‘plantar fasciitis’ (PF) and some authors also
Square, Drake Circus, Plymouth acupuncture for PHP is presented. Quality of the use the term ‘calcaneal spur’. The accuracy of
PL4 8AA, UK; Richard@
IntegrativeHealthcare.co.uk
studies was assessed by independent assessors such terms has been contested6 and they are
with reference to Quality Index (QI), ‘STandards for beginning to be replaced by others, such as
Accepted 14 September 2012 Reporting Interventions in Controlled Trials of ‘plantar fasciosis’.7 However, even this term is
Published Online First
25 October 2012
Acupuncture’ (STRICTA) and ‘CONsolidated inappropriate here, as it embodies the
Standards Of Reporting Trials’ (CONSORT) criteria. assumption that the plantar fascia is the seat
Pooling of data, or even close comparison of of the problem. The aetiology of PHP is
studies, was not performed. complex, involving the interplay of tissue,
Results Five randomised controlled trials and three biomechanical, psychological and other
non-randomised comparative studies were included. factors. These are modelled in different ways
High quality studies report significant benefits. In by acupuncturists (eg, myofascial trigger
one, acupuncture was associated with significant points (MTPs), or disturbances of Qi) and, as
improvement in pain and function when combined Sackett et al8 point out, the practitioner per-
with standard treatment (including non-steroidal spective is an important aspect of the
anti-inflammatory drugs). In another, acupuncture Evidence Based Practice triad. Therefore an
point PC7 improved pain and pressure pain threshold inclusive approach was adopted for this paper
significantly more than LI4. Other papers were of (see Methods and Discussion sections).
lower quality but suggest benefits from other Conventionally many different interven-
acupuncture approaches. tions are used, yet the evidence for their use
Conclusions There is evidence supporting the is inconclusive.9–12 Compliance is often
effectiveness of acupuncture for PHP. This is poor13 and interventions such as non-steroidal
comparable to the evidence available for anti-inflammatory drugs (NSAIDs) and
conventionally used interventions, such as steroid injections carry significant risks.14 15
stretching, night splints or dexamethasone. Recently, increasing numbers of podiatrists
Therefore acupuncture should be considered in are incorporating acupuncture into their prac-
recommendations for the management of patients tices16 and initial results seem favourable.17
with PHP. Future research should recognise the Anecdotally, alumni of a training programme
complexity of PHP, of acupuncture and of the validated by the Society of Chiropodists and
relationship between them, to explore the optimum Podiatrists report good results from incorpor-
use and integration of this approach. There is a ating acupuncture into their approaches.
need for more uniformity in carrying out and Meanwhile the body of published work in
reporting such work and the use of STRICTA is this area is increasing. Thus it is now appro-
recommended. priate to conduct a rigorous assessment of
the role acupuncture might play in the man-
agement of PHP.
INTRODUCTION An earlier systematic review18 addressed a
Plantar heel pain (PHP) is one of the most related question, considering dry needling and
common foot problems and is responsible for injections of MTPs associated with PHP.
substantial morbidity and financial burden.1–4 An Recognising (from clinical experience) that
array of pathologies can give rise to pain beneath many patients experience PHP in the absence
the heel, including vascular, neurological, arthritic of MTPs, the current authors chose to review

298 Acupunct Med 2012;30:298–306. doi:10.1136/acupmed-2012-010183


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Original paper

studies drawing on a wider range of types of acupuncture Two papers were translated.27 28 Data were extracted
practice. into a spreadsheet.
Thus, the research question was: what is the evidence Assessment of the standards of reporting was carried
regarding the effectiveness of acupuncture for PHP? This out using ‘CONsolidated Standards Of Reporting Trials’
paper presents a systematic review of publications relat- (CONSORT) criteria29 (for RCTs) and ‘STandards for
ing to this question, discusses the implications and Reporting Interventions in Controlled Trials of
makes suggestions for future development. Safety was Acupuncture’ (STRICTA) criteria30 and quality of the
not considered in this review; this aspect has been studies was assessed using the Quality Index (QI).31 To
studied more appropriately elsewhere.19–22 enable comparison, the QI scale was modified as recom-
mended by Cotchett et al18 (however, only one paper
appeared in both studies, so meaningful comparison was
METHODS impossible). The two authors rated each paper independ-
The protocol was registered with PROSPERO (no. ently; scores were discussed to identify and resolve differ-
CRD42012001881).23 Recognising the heterogeneity in ences, and so achieve consensus. Percentage scores were
the reporting of this phenomenon, a broadly inclusive calculated in relation to the number of relevant items, to
search strategy was chosen to identify relevant work. enable comparison across the scales. Further quality data
A comprehensive literature search was carried out as were extracted.
follows. The databases searched were: PubMed, AMED Narrative summarisation was performed; neither data
(EBSCO), British Nursing Index, CINAHL plus (EBSCO), synthesis nor meta-analysis was possible.
EMBase, MEDLINE (EBSCO), MEDLINE (Ovid), Oxford
Journals, PsychARTICLES, ScienceDirect, SocINDEX RESULTS
(EBSCO), SwetsWise, Taylor & Francis Online and Wiley Papers
Online Library. The search identified 342 potentially relevant articles (see
The search parameters included All Dates (from incep- figure 1), of which 8 met the inclusion criteria: 5
tion to the end of 2011), All Types of publication, All RCTs,27 28 32–34 2 non-randomised comparative studies35 36
Languages and All Fields. The precise wording of the and 1 cohort study using ‘patients as their own controls’.37
searches varied in different databases, using different the- A summary of the papers is provided in tables 1–3, and
sauri. The general principle was to include ‘Acupuncture’ quality assessment is summarised in table 4.
OR ‘dry needl*’ OR ‘Trigger Points’ OR ‘moxibustion’
OR ‘TENS’ OR ‘laser therapy’ AND ‘heel pain’ OR
‘plantar fasci*’ OR ‘heel spur’ OR ‘calcan*’. Quality
The search was extended by following all relevant The parallel use of STRICTA, QI and CONSORT gave a
leads in the sources read. Reference lists of papers multifaceted appreciation of the overall quality of the
obtained were scanned for further relevant papers. studies and their reporting. There was reasonable agree-
Journals identified were searched electronically where ment between the rankings by the three instruments.
possible, or by scanning tables of contents. Leads were Table 4 illustrates the wider quality issues of clinical and
also obtained from available textbooks, online forums research ethics governance, revealing weak methodology
and the internet and personal communications. in most of the papers. No papers declared their commis-
Titles and abstracts were scanned to identify papers for sioning or peer review status (although three appeared in
inclusion. Papers relating to PHP and related diagnoses peer-reviewed journals). Only two declared funding
were included; those relating to pain secondary to other received. Five papers appeared in acupuncture-focused
pathologies,24 25 or to experimental pain in animal sub- journals; three studies took place in colleges of TCM.
jects26 were excluded. The relationship between clinical practice and research
Papers were included if they described the use of acu- was often blurred (indicating potential for Hawthorne
puncture, acupuncture points, Traditional Chinese effect and social desirability bias) and there was a lack of
Medicine (TCM) or moxibustion. Papers describing the transparency regarding ethical governance. However, two
use of MTPs were included if the treatment was (dry) papers32 34 achieved high standards by most of these cri-
needling, whether or not an acupuncture-related rationale teria and this is reflected in their high QI ratings.
was used. Papers describing the use of laser therapy or
transcutaneous electrical nerve stimulation (TENS) were Individual papers
included only if the treatment was applied specifically to Karagounis et al32 assessed the value of adding acupunc-
acupuncture points, or if an acupuncture-related rationale ture treatment to a standard clinical approach, for men
was used.27 with acute PF. While the ‘standard’ group showed
Randomised controlled trials (RCTs) and non- improvement ( pain score reduced 26%), the acupuncture
randomised comparative studies were included. Case group improved almost twice as much (47%, p<0.05).
series, single case studies and secondary reports were This is a high quality study with good internal and exter-
excluded from this review but will be considered in detail nal validity, and well reported. The treatment used was
elsewhere (unpublished results). semi-individualised and the detail provided for the

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Original paper

Figure 1 Flowchart for selection of papers.

acupuncture given is not enough for precise duplication uncontrolled and non-blinded study and so has low
of the process. scores on internal validity; also the quality of reporting is
Zhang et al34 assessed the specific efficacy of acupunc- moderate by modern standards. However the approach
ture point PC7 (compared to LI4) for PF of over 3 months used is very relevant to clinical practice. The authors
duration. They concluded that PC7 gives a significantly argue that each patient served as their own comparator
greater benefit, at 1 month and 6 month follow-up. This in view of the long duration of the issue, with failure of
trial scores well on internal validity, less so on external prior treatments. Comparison is also possible between
validity. the two phases of the study, however without concur-
One might criticise the choice of LI4 as a comparator, rent control groups one cannot eliminate change due to
in that it is widely used to treat pain, including heel pain non-specific factors.
(eg, Price38). Conversely, this makes it ideal as a ‘control’ Orellana Molina et al27 studied pain related to heel
treatment; if LI4’s reputation is undeserved and it is, in spurs, comparing the effectiveness of laser treatment at
fact, an inert intervention, then it serves as a demon- acupuncture points with needling a similar group of
strably credible placebo; conversely, if it is an effective points, chosen according to the traditional ‘eight princi-
point, then PC7 has been shown to be even more so. ples’ approach. While both groups showed benefit, the
Tillu and Gupta37 studied a series of 18 consecutive laser group reported improvement sooner and to a greater
patients with PF of over a year duration. All had failed to degree. Significance is claimed for this result but (even
benefit from prior conservative treatments, including after professional translation) the statistical method used
steroid injection in 12 cases. Patients received acupunc- is unclear.
ture to ‘classical points’ (KI3, BL60, SP6), weekly for Vrchota et al33 studied the efficacy of ‘true acupunc-
4 weeks, which resulted in significant improvement of ture’ (TA) compared to ‘sham acupuncture’ (SA) and to
mean visual analogue scale (VAS) pain scores ( p<0.0009). ‘sports medicine therapy’ (SMT) for PF in a sports medi-
There were 2 patients that needed no further treatment; cine clinic. TA included the use of ah shi, local trigger
the remaining 16 were then given the same treatment points and classical acupuncture points, to which electro-
twice more, with the addition of needling ‘trigger points acupuncture was applied at the level of tolerance. SA con-
in the gastro-soleus and plantar fascia’. This resulted in a sisted of shallow needling at two unrelated points on the
significant further improvement ( p<0.047). This was an sole, with minimal electroacupuncture (below threshold

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Original paper

Table 1 Higher quality trials*


Study, Participant Comparison
type (N) characteristics Acupuncture intervention† intervention(s) Outcome measures Results/conclusions
Karagounis PF Group 2: up to 12 painful Group 1: standard PFPS (PF pain scale; Both groups improved
et al32 Duration >2 weeks and other points chosen treatment including: Willis et al42) significantly, group 2 more so.
DBRCT (38) (mean 16.1 days) from a list of 18 classical ice, extensive At week 8 improvement = group
100% male acupuncture points. stretching programme 1 26%, group 2 47%; p<0.05
Mean age 37.1 Slight rotation and thrusting and NSAID drug Minor adverse effects noted.
No prior treatments to elicit de qi (dull, numb or
received. heavy). Retained
20–30 min, with ‘periodic
manual stimulation’.
16 sessions, 2/weeks.
Plus standard treatment as
group 1.
Zhang et al34 PF (diagnosed as ‘pain Group 1: PC7, contralateral Group 2: LI4, VAS for MP, AP, OP Significantly greater improvement
DBRCT (53) localised to the medial to pain. contralateral to pain. also pressure in group 1 than group 2 at four
tubercle of the Depth 10 mm. De qi Depth 10 mm. De qi algometry (PP) at each data points. Significant decrease
calcaneum’) elicited each 5 min; elicited each 5 min; daily session and in MP (from baseline) seen in
Duration >3 months Retained 30 min. Retained 30 min. follow-up at 1, 3 and group 1 at 1, 3 and 6 month
(3–216 months) Daily ×10 Daily ×10 6 months follow-up (p<0.001). Both
26.4% male groups showed significant
Age >18 (mean decreases in AP and OP. Group 2
age 48.5) non-significant improvement in
Various prior MP. Negative correlation found
treatments between prior duration of issue
and improvement.
One dropout due to needling pain
at LI4.
*These two trials scored higher than all the others in terms of quality of trial and of reporting, as indicated by Quality Index (QI), ‘STandards for Reporting
Interventions in Controlled Trials of Acupuncture’ (STRICTA) and ‘CONsolidated Standards Of Reporting Trials’ (CONSORT) scores (see table 4).
†In original papers, acupuncture points were named according to different conventions; where necessary, these have been translated to the WHO
recommended format (eg, the point Xiaguan is rendered as ST7).
AP, activity pain; DBRCT, double-blind randomised controlled trial; de qi, the characteristic feeling produced by the needle; MP, morning pain;
NSAID, non-steroidal anti-inflammatory drug; OP, overall pain; PF, plantar fasciitis; VAS, visual analogue scale.

of perception). The SMT group received advice to reduce their treatment was different from the ‘common’ treat-
training, apply ice, stretching exercises and NSAID medi- ment. The ethics of this is not discussed. The outcome
cation. Pain reduction was significantly greater in the TA measure used is a point score derived from subjective
group than the SMT group after four treatments and reporting. Variants of this approach are common in
3 weeks later. The results in the SA group were inter- Chinese clinical studies over the past few decades, but no
mediate between the other two groups, but differences validation is mentioned.
did not reach significance. This paper lacks many details Ouyang and Yu36 studied patients with pain in the
including: demographic characteristics, duration of issue, sole (including an unstated number in the heel), compar-
prior treatments and blinding. Thus, TA appears more ing the use of ST7 with a ‘corresponding point’ on the
effective than SMT but questions remain as to which palm, or both of these combined. (Corresponding point is
aspects are important, and the possible confounding assumed to mean a location on the palm analogous to
effect of other variables. the pain location on the foot but this is not made expli-
Liu et al28 studied the effectiveness of needling a single cit.) They conclude that the combination is more effect-
point (GB39) in conjunction with local heat application ive, however the differences are small and unlikely to be
via a herbal dressing, in comparison to ‘common acu- of statistical significance. This paper reports outcomes as
puncture’ needling four other points, for patients with clinical judgements of relief obtained (complete, marked,
chronic pain related to heel spurs. Using a combined partial, none) and, unlike comparable papers, combines
‘points reduction rating’ they found significantly greater the first three into a global response rate. When ‘partial’
improvement in the ‘GB39 plus heat’ group (‘marked is excluded (by the current authors, to reflect more
improvement’ in 64.7% compared to 37.5%; p<0.05). common practice) ST7 emerged as more effective than
This is described as a single blind study, with patients the Palmar point (76.5% compared to 59.3%).
uninformed. No concealment of treatment is described; it Furthermore, needling the palm was found to be too
is assumed that patients were simply not informed that painful for some patients, so the recommendation was to

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Table 2 Other randomised controlled trials


Study, Participant
type (N) characteristics Acupuncture intervention* Comparison intervention(s) Outcome measures Results/conclusions
28
Liu et al ‘Calcaneus spur’ Group 1: GB39 Group 2: ‘common PRR based on walking Both groups PRR >50%. PRR
(Chinese) (on x-ray) Duration Even method, de qi to heel, acupuncture’: GB34, BL60, pain, walking function, of over 60% for 64.7% group
RCT (66) 4–38 months retained 20 min. BL57, KI3. Ipsilateral. swelling, burning 1, 37.5% group 2, p<0.05.
37.9% male Daily, 30 sessions during 3 sensation, each on a Asserts safe, but without
Age 31–64 courses of 10, plus pyrogenic five-point scale giving data.
Prior treatments herbal dressing and heat
not stated application.
Orellana Heel spur (but Group 2: Acupuncture to Group 1: Point application of VAS pain scores at Group 1: cure 11/26;
Molina diagnosed ah shi, BL40, BL60, KI3, KI6. infrared laser (904 nm) to ah sessions 3, 6, 10 improved 15/26
et al, 1996 clinically) Rotate at start and at 10 min. shi, BL40, BL60 combined into 3 Group 2: cure 16/26,
(Spanish) Duration not stated Retain 20 min. Daily ×10, 16 J/cm2 to ah shi, 7 J/cm2 categories: improved 10/26
RCT (52) 30.8% male repeat if necessary. to other points. Cured=VAS≤2 Also group 2: onset of benefit
Age < 40 to > 60 Daily ×10, repeat if Improved=VAS 3–5 sooner; fewer patients
Prior treatments necessary. Not improved=>5 required second course
not stated.
Vrchota PF Group 1, ‘true acupuncture’: Group 2, ‘sham acupuncture’: Pain score, tenderness Mean pain score >50% less.
et al33 Duration not electroacupuncture to KI1, KI3, sham points on sole, minimal score, decided by Significant difference.
DBRCT (40) stated ah shi; 5/80 Hz, to tolerance. depth, subthreshold doctor with patient, True>sham>sports medicine
Gender not stated Retained 20 min, plus calf electrostimulation. Plus calf each on a four-point (including NSAID drug).
Age not stated stretches, footwear advice, stretches, footwear advice, scale. Pain log showed more relief
Prior treatments insoles. insoles. Pain log, daily until in group 1 than group 3 at
not stated Group 3, ‘sports medicine 3 weeks after last week 4 (p=0.010) and
therapy’, including reduced treatment. follow-up (p=0.016).
training, stretches, ice and Activity log (data not Pain score showed more
NSAID. Plus footwear advice, used) relief in group 1 than group 3
insoles. at week 4 (p=0.014).
Tenderness scores changed
little
Ah shi, the point of maximum tenderness; DBRCT, double-blind, randomised controlled trial; de qi, the characteristic feeling produced by the needle;
NSAID, non-steroidal anti-inflammatory drug; P, probability value; PF, plantar fasciitis; PRR, points reduction rate; RCT, randomised controlled trial;
VAS, visual analogue scale.

use ST7 as first choice and reserve palmar needling for outcomes however they are heterogeneous in several
unresponsive cases. This approach is not widely known ways, making it difficult for simple conclusions to be
in the West and challenges the professional boundaries of drawn.
some practitioners (eg, podiatrists, who would not nor-
mally needle the face), yet the response rates reported
here seem promising. Heterogeneity
Chen and Zhao35 retrospectively reported an extensive The STRICTA scores achieved by these papers range
series of patients with heel pain. They compared the from 46.9 to 94.1%. This is unsurprising because five of
results of 50 receiving acupuncture to BL61 ( plus an indi- them were published before the STRICTA guidelines
vidualised herbal decoction), with 102 receiving steroid were available. The highest scores were obtained by the
injection into tender point ( plus herbal decoction) and three most recent papers. Future studies should be more
with 748 receiving steroid alone (5–6 injections during rigorous in adhering to these guidelines.
3 weeks). They stated that there was no significant differ- The indication for treatment is variously stated as heel
ence between the ‘effective rate’, which averaged 73.5% pain (although one paper is less precise), PF (but the defini-
in the three groups. The statistical method used is not tions differ) or heel spur (with or without x-ray confirm-
stated and, on close inspection of their data, the numbers ation). The problem of diagnostic labelling for heel pain was
in the table do not add up to the totals given, so it is discussed above. Authors of the papers reviewed showed
impossible to draw a conclusion from this. variable awareness of the shortcomings of these terms. The
assumptions underlying such labels are now seen to be
DISCUSSION incorrect, yet it is likely that they influence the design of
A systematic search identified eight papers providing evi- treatments. For example, if the focus is on ‘inflammation’,
dence regarding the effectiveness of acupuncture for PHP. then acupuncture points thought to influence inflammation
Two studies provide good reporting of high quality may be chosen; meanwhile a potentially more useful
studies; six are of lesser quality. All report positive approach (eg, treating MTPs) may be overlooked.

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Table 3 Non-randomised studies


Participant Acupuncture Comparison intervention
Study, type (N) characteristics intervention* (s) Outcome measures Results/conclusions
35
Chen and Zhao Heel pain, mostly Group 3 BL61 Group 1: steroid+LA local Excellent=complete Three groups
Non-randomised non-specific Depth 0.3–0.5 cun point, ×5–6 in 3 weeks resolution comparable, no
comparative case ±calcaneal spurs Retained 5 min Group 2: as group 1 plus Good=remarkable significant difference
series (900) Duration 3 months 10 sessions, daily, during individualised herbal improvement Acupuncture group:
to 30 years 2 weeks plus herbs as in decoction twice a day Poor=no response excellent 15/50, good 20/
33.3% male group 2 ×15 50, poor 15/50 (allowing
Aged <30 to >70 for typo); follow-up 1–
Prior treatments not 8 years (mean 3.5)
stated
Ouyang and Yu36 ‘Pain in the sole’ Group 1: ST7, ipsilateral. Group 2: ‘corresponding’ CR=complete relief RR%=97.1 (group 1);
Non-randomised (including heel) Depth 1.5 cun; Rotation palmar point, ipsilateral. MR=marked relief 92.6 (group 2); 100
comparative Duration 1–6 months 1 min counterclockwise; Depth 0.5 cun; rotation PR=partial relief (group 3)
clinical trial (73) (N=14); >1 year Retain 20–30 min. 1 min counterclockwise; NR=no relief Concludes combination is
(N=29); 3 years Daily ×5 per course. retain 20–30 min. CR+MR+PR=RR more effective, but
(N=1); rest not stated Daily ×5 per course palmar points often
43.8% male Group 3: ST7 and palmar painful, so use latter only
Age 30–78 point if ST7 fails
Prior treatments not
stated
Tillu and Gupta37 PF ‘Classical acupuncture Trigger points (calf and VAS pain score; Significant reduction from
Prospective case Duration points’ KI3, BL60, SP6; plantar) added if needed VAS % change; baseline in VAS scores at
series with 12–30 months ipsilateral; de qi sought for sessions 5–6 verbal rating score week 4 (40.3%)
’self-controls’ (18) 27.8% male (tingling) each 5 min; (p<0.0009) and week 6
Mean age 49.17 retained 15 min. (69%) (p<0.0001)
(SD 10.66) Weekly ×4. Significant reduction
Previously between week 4 and
unsuccessful week 6 (p<0.047)
conservative treatment Concludes classical
(physiotherapy, shoe acupuncture points
support, steroid effective, enhanced by
injection) addition of trigger points
in failed cases.
Recommends use of
MTP from the start.
Cun, a standard measurement used in acupuncture practice; de qi, the characteristic feeling produced by the needle; LA, local anaesthetic; MTP, myofascial
trigger point; PF, plantar fasciitis; RR, response rate; VAS, visual analogue scale.

An earlier systematic review18 focused exclusively on However one study32 included only male patients, which
MTPs. While this has the merit of simplicity, it may not may be a significant confounding factor; recent papers
reflect a reality that is complex. This review has shown highlight effects of patient or practitioner gender on per-
that MTPs may give additional benefit when added to ceptions of pain and acupuncture.39–41
classical acupuncture37 and also that acupuncture unre- The outcome measures vary from precise, prospective
lated to MTPs confers significant benefits.34 Clinical use of relevant pain scales (VAS, PF pain scale (PFPS)42)
experience (RJC) shows that some patients have MTPs to retrospective clinical judgements. All assessed subject-
related to their heel pain and others do not; there is a need ive pain, some assessed function and one assessed tender-
to explore the possibility that these are two pathologically ness objectively.
distinct groups, requiring different treatment approaches. Perhaps the greatest difference between these papers is
Prior duration of the issue, where stated, varied the treatment approach used: although all studies involve
between 2 days and 30 years. This is perhaps of particular acupuncture, none of them use the same approach. This
significance in that one paper34 noted an inverse correl- should remind us that acupuncture is not a unitary inter-
ation between duration and benefit obtained, which sug- vention; indeed, it is very complex.43
gests that it would be prudent to control for duration in
future studies. Limitations of this paper
The gender ratio also varied. In most papers it was Bias
between 26.4 and 43.8% male, which is comparable to As a practising acupuncturist, one author (RJC) might be
the distribution of heel pain in the general population. biased in favour of a positive outcome. However, any

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Table 4 Evaluation of trial reporting and trial quality


Authors, QI STRICTA CONSORT Ethical Notes re: publication
place % % % governance bias Randomised Blinding Setting
Karagounis 85.2 78.1 44.6 Informed written ‘No sources of Computer Patients and University Laboratory of
et al32 consent funding’ generated assessor Functional Anatomy and Sports
(Greece) Medicine
Zhang et al34 72.2 94.1 75.0 Ethical Partially supported by Computer Patients and School of Chinese Medicine,
(China) committee faculty research grant generated assessor. and Department of TCM
approval Credibility rated.
Tillu and 66.7 55.9 – ‘Patients … Acupuncture journal No No Departments of Orthopaedics
Gupta37 (UK) willing to and Anaesthetics
participate’
Orellana 61.1 52.9 41.7 Informed consent States ‘no conflicts of Yes, method No Center for Technological
Molina et al interest’ not stated Applications and Nuclear
(Cuba) Development and National
Rheumatology Service
Vrchota et al33 51.9 46.9 40.3 Patients recruited Acupuncture journal Yes, method Implied, Pain clinic and research centre,
(US) via newspaper not stated patients and Department Neurology and
advert assessor Family Practice
Liu et al28 50.0 64.7 41.4 Written consent Acupuncture journal Yes, method Patients TCM College Hospital and
(China) not stated University Hospital
Ouyang and 20.4 61.8 – Avoidance of Acupuncture journal No No Military Medical University
Yu36 (China) painful point ‘wish to present the
satisfactory results’
Chen and 11.1 55.9 – – Acupuncture journal No No Academy of TCM and County
Zhao35 (China) Hospital
CONSORT, ‘CONsolidated Standards Of Reporting Trials’; QI, Quality Index; STRICTA, ‘STandards for Reporting Interventions in Controlled Trials of
Acupuncture’; TCM, Traditional Chinese Medicine.

such bias should be apparent, if not neutralised, by the demonstrated a worthwhile level of effect, using a treat-
transparency and systematic nature of this review. ment approach which is much closer to real-world practice,
and it scored well on external validity.
Publication bias
Positive outcomes
Five of the papers reviewed were published in acupunc- CONCLUSIONS
ture journals, with unknown peer-review standards, so it In view of the heterogeneity of these papers, it is not
seems likely that there is a bias in favour of positive find- possible to give a simple conclusion, in the form ‘X is
ings, particularly as they date back as far as 1985. shown (or not) to be efficacious for Y’. A number of dif-
However the two higher quality papers were published ferent approaches were identified, which indicate poten-
in peer-reviewed non-acupuncture journals, so we place tial uses of acupuncture for treating heel pain, as
more confidence in them. It is impossible to know if summarised in box 1.
there were similar studies with negative outcomes that Thus there is evidence at level I and II supporting the
remain unpublished. effectiveness of acupuncture for heel pain, leading to a
recommendation at Grade B.44 This is comparable to the
Positivist methodology evidence available for conventionally used interventions,
Including RCTs but excluding case studies, imposes a such as stretching, night splints or dexamethasone.10
bias towards formulaic (rather than individualised) Therefore acupuncture should be included in recommen-
approaches. This fails to reflect the reality of practice. dations for the treatment of PHP.
Sackett notes the importance of this: ‘Evidence based Future research should avoid the simplistic question ‘Is
medicine … requires a bottom up approach that inte- acupuncture efficacious for heel pain?’ and instead focus
grates the best external evidence with individual clinical on exploring the optimum use of acupuncture for heel
expertise and patients’ choice’.8 pain. The field is not yet ripe for RCT studies. We are
At this point it is worth comparing the two high-scoring currently at the ‘development’ stage as defined by the
papers: Zhang et al34 is a rigorous and well-reported double- Medical Research Council45—this paper is ‘identifying
blind RCT, high on internal validity. However the interven- the evidence base’ and the next two phases (identifying/
tions compared bear little relation to common practice, and developing theory, and modelling process and outcomes)
the effect size is small. In contrast, Karagounis et al32 are being addressed in a separate study.

304 Acupunct Med 2012;30:298–306. doi:10.1136/acupmed-2012-010183


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The effectiveness of acupuncture for plantar


heel pain: a systematic review
Richard James Clark and Maria Tighe

Acupunct Med 2012 30: 298-306 originally published online October 25,
2012
doi: 10.1136/acupmed-2012-010183

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