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Education, practice and debate
The clinical effectiveness of acupuncture for pain
relief – you can be certain of uncertainty
Mark I Johnson
Abstract
Nowadays the volume of published research is so overwhelming that practitioners are turning to expert
groups to interpret and summarise research for them. This paper critically reviews the processes used to
establish one-sentence statements about the effectiveness of acupuncture for pain relief. Some one-sentence
statements claim that acupuncture is not clinically effective because systematic reviews of clinical trials find
similar amounts of pain relief between sham acupuncture and real acupuncture. However, these one-sentence
statements fail to account for shortcomings in clinical trials such as inadequate doses and inappropriate
acupuncture technique. Establishing the physiological intention of acupuncture and developing criteria to assess
whether this has been achieved in trials will help to overcome some of these problems in future trials. In addition,
shortcomings in systematic review methodology such as imprecise inclusion criteria, comparisons of
heterogeneous study populations and imprecise definitions of acupuncture have resulted in discrepancies
in vote counting of outcomes between review groups. Recognition of these issues has produced a shift in favour
of acupuncture in recent systematic reviews and meta-analyses. It is hoped that this will be reflected in a
reappraisal of some of the negative one-sentence statements about the effectiveness of acupuncture for pain
relief.
Mark I Johnson
professor of pain and
analgesia
School of Health and
Human Sciences
Leeds Metropolitan
University
Leeds, UK
M.Johnson@
LeedsMet.ac.uk
Keywords
Acupuncture, systematic review, meta-analysis, evidence based medicine.
Introduction
Clinical experience suggests that acupuncture reduces
pain, but a causal relationship cannot be established
by clinical experience alone. This is because clinical
experience cannot determine whether pain relief was
due to spontaneous improvement of the ailment,
natural fluctuations in symptoms, the patient’s
expectation that acupuncture should work, or the
patient exaggerating their report of the effect of
acupuncture to please the therapist. Controlled clinical
trials help to establish whether treatment effects are
due to the therapeutic agent of the treatment or due to
some other confounding factor. With so many clinical
trials and systematic reviews of clinical trials of
medical treatments, expert groups have emerged to
interpret the research and provide simple statements
about effectiveness. The purpose of this paper is
twofold. First, to encapsulate the clinical research
facing practitioners trying to establish the ability of
acupuncture to relieve pain, and secondly, to critically
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review the processes used to establish one-sentence
statements about effectiveness. However, it is
important at the outset to demonstrate why it is
imperative to attempt to establish clinical
effectiveness and for practitioners to act on the
outcome.
Fake treatments and their unintentional use
In 2004, Dr Copperfield, columnist in the British
newspaper The Times, Body and Soul supplement
wrote: ‘Most of us [GPs] realise that our job is to
keep patients distracted while they get better for
themselves.’1 This ‘tongue in cheek’ comment raises
an interesting ethical debate. One could in principle
distract a patient through deception, by giving them a
fake treatment that was known to have no therapeutic
agent (active ingredient). This could be in the form a
placebo pill or a sham procedure. It would ‘trick’ the
patient into believing that they were receiving a
treatment with a therapeutic agent when in fact they
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Education, practice and debate
were not. Clearly, the routine use of fake treatments to
deceive patients while they get better for themselves
is ethically unacceptable, and if patients were to find
out it would undermine their confidence in the health
care profession. For this reason, it is difficult to justify
the argument that it does not matter how you relieve
a patient’s pain providing that you do, unless perhaps
as a last resort when all else fails. Interestingly, a 2004
survey suggests that the intentional use of fake
treatments (placebos) may still be commonplace in
medical practice in some countries.2
People often associate fake treatments with
pseudoscience and quacks. Definitions of ‘quacks’
include ‘an unqualified person who dishonestly claims
to have medical knowledge’,3 or a ‘pretender to a
medical skill; charlatan’.4 Clearly, qualified health
care practitioners are not quacks. However, if as a
last resort they were knowingly to administer a fake
treatment without informing the patient that they
were doing so, they could be accused of momentarily
acting as charlatans, albeit in the best interests of the
patient. Interestingly, the Federal Drug and Food
Administration definition of health fraud is ‘the
promotion for profit, of a medical remedy known to be
false or unproven’.5 Because good quality clinical
trials are difficult to conduct, treatments are often
‘proven’ in terms of their scientific rationale rather
than their clinical effectiveness. However, medical
history reveals many examples of treatments and
procedures that appear at the time to have a scientific
rationale but are eventually found to have no
therapeutic agent or value. In some situations the
treatments and procedures may do serious harm, as
was the case for trepanation, blood letting, mercury,
and more recently insulin coma therapy in
schizophrenia. Because many present day treatments
have unproven clinical effectiveness it is likely that
practitioners are unintentionally using some treatments
that have no therapeutic agent (ie fake treatments).
This is acceptable because legislation that restricted the
use of treatments with unproven clinical effectiveness
would prevent the development of potentially
beneficial treatments. It is logical, therefore, for
practitioners provisionally to use treatments of
‘unproven’ clinical effectiveness, even though the
treatment may eventually be shown to have no active
therapeutic agent and no clinical effectiveness.
Nevertheless, it is imperative that attempts are made
to establish clinical effectiveness to avert accusations
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that a treatment with unproven clinical effectiveness
is inert. Interestingly, it has been shown that some
practitioners continue to use their favoured treatments
even if the bulk of scientific evidence suggests that the
treatment is not clinically effective.6
Criticisms of acupuncture
Acupuncture has not been immune from criticism
about its effectiveness. In the UK, the BMA approval
of acupuncture was met with disdain in some
quarters, with claims that ‘The BMA report is quite
simply wrong’.7 In the USA, the National Council
Against Heath Fraud (NCAHF) which is ‘a private
non profit, voluntary health agency that focuses upon
health misinformation, fraud, and quackery’,
produced a position statement on acupuncture in
1990, which is still prominent on its web site today.8
It states that:
‘Acupuncture is an unproven modality of
treatment; its theory and practice are based on
primitive and fanciful concepts of health and disease
that bear no relationship to present scientific
knowledge; research during the past 20 years has
failed to demonstrate that acupuncture is effective
against any disease; perceived effects of acupuncture
are probably due to a combination of expectation,
suggestion, counter-irritation, operant conditioning,
and other psychological mechanisms; the use of
acupuncture should be restricted to appropriate
research settings; insurance companies should not
be required by law to cover acupuncture treatment;
and licensure of lay acupuncturists should be phased
out.’
NCAHF advises physicians that: ‘acupuncture
should not be offered without full informed consent,
reminding patients that acupuncture is experimental,
has not been proven more effective than a placebo,
and has some risk of complications.’8 Acupuncturists
would, quite rightly, argue that these emotive
statements do not reflect current scientific and clinical
knowledge on acupuncture. Clearly, there is a
discrepancy in the interpretation of the ‘knowledge’,
so it is necessary to assess how knowledge on clinical
effectiveness is gathered.
Evidence based medicine, clinical effectiveness
and active ingredients
Evidence-based medicine (EBM) integrates clinical
experience with systematic clinical research to
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determine best practice. A cornerstone of EBM is
establishing clinical effectiveness and exposing the
unintentional use of interventions with no therapeutic
value.9 A treatment is clinically effective when
beneficial effects can be attributed to its therapeutic
agent and this is achieved by distinguishing the
clinical effects associated with receiving the treatment
from those associated with the therapeutic agent of
the treatment. Therapeutic agents give treatments
their uniqueness and identity, and for drugs it is often
a unique chemical structure. For complex techniquebased interventions underpinned by different
philosophical principles the therapeutic agent may
be difficult to define.
you are not. Pretend or bogus interventions (sham
interventions) and substances with no therapeutic
effect (placebo interventions) are used in clinical
research to isolate the effects associated with the
therapeutic agent of the treatment. Sham and placebo
controls help to control for natural fluctuations in
symptoms over time and the patients’ expectations
about the treatment and its effects. This is important
because we know that in medicine ‘Doing nothing
causes things to happen’.11 Sham acupuncture could
include administering needles that do not pierce the
skin or administering needles at non-specific
acupuncture points. Ideally the sham acupuncture
intervention should consist of both.
Determining the identity and effectiveness of
acupuncture
The uniqueness and identity of acupuncture appears
to be the process of inserting needles in the skin at
chosen points (Latin acu ‘with a needle’; Latin
punctura, from pungere ‘to prick’). The Oxford
dictionary defines acupuncture as ‘a system of
complementary medicine in which fine needles are
inserted in the skin at specific points along supposed
lines of energy.’10 If needles are not ‘inserted’ or
‘specific points’ are not used, then, by strict definition,
the treatment is not acupuncture (though a modern
definition should obviously include specific points in
accordance with known physiological or anatomical
rationale).
Two key questions arise:
(i) Do you have to insert needles in the skin to
produce a clinically meaningful effect?
(ii) Does it matter where in the skin these needles
are inserted to produce a clinically meaningful
effect?
If the answer to either of these questions is no, then
it would start to bring into question the value of
acupuncture, in its strictest definition, as a clinically
effective treatment.
Relative effectiveness
In clinical practice where practitioners need to select
from a range of potential treatments, information
about relative effectiveness is more useful because it
compares the effectiveness of treatments ‘head-tohead’. However, clinical trials that attempt to establish
the relative effectiveness of acupuncture against other
treatments often score low on methodological quality
rating scales because it is notoriously difficult to
blind trial participants to treatment groups. Despite
the difficulties in designing and executing
effectiveness trials on acupuncture the amount of
published clinical research available overwhelms
most practitioners.
Absolute effectiveness
To establish absolute effectiveness for acupuncture it
would be necessary to demonstrate that inserting
needles in the skin at specific points produced
clinically meaningful effects over and above
everything except inserting needles in the skin at
specific points, ie ‘pretending’ that you are inserting
needles in the skin at specific points when in fact
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Interpreting clinical research on acupuncture
A broad free text search on PubMed using the key
word ‘acupuncture’ conducted on 7 March 2006,
identified 10257 hits. Restricting the search to
‘acupuncture’ and ‘pain’ reduced to 2674 hits, of
which 392 were clinical trials, 259 RCTs and 25
meta-analyses. It is impossible for practitioners to
read and interpret such a volume of information so
expert groups have emerged to interpret the research
for them. These expert groups include Bandolier,
The Cochrane Collaboration and the National Health
Service Centre for Reviews and Dissemination
(CRD).
Bandolier
Bandolier is an independent journal written by
Oxford scientists and it claims to provide ‘Evidence
based thinking about health care’.12 Bandolier’s Little
Book of Pain is a pocket sized evidence based guide
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to treatments and uses ‘Clinical Bottom Lines’ to
aid quick and easy decision making.13 The clinical
bottom lines for acupuncture include:
‘Acupuncture is ineffective for back pain’ (p365);
‘There is no convincing evidence demonstrating that
acupuncture is more effective than placebo for the
relief of back or neck pain’ (p366); ‘There is no
evidence for efficacy of acupuncture in fibromyalgia’
(p366); ‘There is no evidence that acupuncture is
more effective than sham/placebo acupuncture for
the relief of joint pain due to osteoarthritis (OA)’
(p366).
In addition, the following Clinical Bottom Lines
appear on Bandolier’s web site:
‘Based on a very small number of trials, there is
no convincing evidence for the effectiveness of
acupuncture in relieving dental pain.’14
‘There is no evidence from high quality trials
that acupuncture is effective for the treatment of
migraine and other forms of headache.’15
‘...bottom line is that the use of acupuncture for
chronic pain is unsupported by any evidence of
quality. Consumers and providers should
beware.’16
These statements should alarm acupuncturists
because Bandolier, and its Little Book of Pain, has
much influence within medical and allied health care
professions.
Cochrane Collaboration
The Cochrane Collaboration Library claims to be
‘The reliable source of evidence in Health Care’.17
A search of the Cochrane database of systematic
reviews on 7 March 2006 using the key word
‘acupuncture’ in all fields, yielded 172 hits (121
reviews and 51 protocols). Restricting the search to
‘acupuncture’ and ‘pain’ in all fields yielded 105 hits
(76 reviews and 29 protocols), and further restriction
to ‘acupuncture’ in record title and ‘pain’ in all fields
yielded 19 hits (13 reviews and six protocols).
Of these 13 reviews, six examined pain
outcomes. Two reviews concluded that acupuncture
was effective, one for idiopathic headache,18 and one
for chronic low back pain up to three months.19 One
review found acupuncture to be ineffective for
improving symptoms of rheumatoid arthritis.20 The
remaining reviews reported insufficient evidence to
make definitive conclusions for shoulder pain,21
lateral elbow pain,22 and primary dysmenorrhoea,23
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although these three reviews found poor quality
evidence hinting that acupuncture may be of benefit.
The non-pain reviews captured by the search reported
that acupuncture was effective for preventing nausea
and vomiting,24 and ineffective for the treatment of
cocaine dependence. 25 There was insufficient
evidence to make definitive conclusions for smoking
cessation, 26 induction of labour, 27 symptoms of
depression, 28 acute stroke, 29 and Bell’s palsy. 30
However, this is not an exhaustive list of reviews on
acupuncture for non-pain conditions as the search
was restricted to pain in all fields.
Interestingly, one review of acupuncture and pain
has changed in its conclusion over time, as new and
better quality RCTs became available. A review on
acupuncture for low back pain originally concluded
that: ‘The evidence summarised in this systematic
review does not indicate that acupuncture is effective
for the treatment of back pain’ [Reviewers
Conclusion].31 An update of this review was more
positive: ‘For chronic low-back pain, results show
that acupuncture is more effective for pain relief than
no treatment or sham treatment, in measurements
taken up to three months’ [Plain Language
Summary].19 The conclusion of the update is consistent
with a recently published meta-analysis on
acupuncture for low back pain which was conducted
by a different team of investigators.32 It is likely that
this trend of ‘shifting knowledge’ will continue as
better quality primary research is conducted.
National Health Service Centre for Reviews and
Dissemination (CRD)
With so much information, the National Health
Service Centre for Reviews and Dissemination
(CRD) produced a Health Care Bulletin in 2001 that
reviewed all available systematic reviews and metaanalyses.33 The CRD claims to ‘Promote(s) the use of
research based knowledge in health care’,34 and it
concluded that:33
‘Acupuncture appears to be effective for
postoperative nausea and vomiting in adults, chemotherapy related nausea and vomiting, and for
postoperative dental pain.’ [p1]
‘Current evidence suggests that acupuncture is
unlikely to be of benefit for smoking cessation and
tinnitus.’ [p1]
‘For most other conditions the available evidence
is insufficient to guide clinical decisions. The most
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problematic area is chronic pain where there is a
large body of data open to conflicting interpretations.’
[p5]
The large body of data reviewed by the CRD
consisted of 19 systematic reviews and/or metaanalyses. There were three reviews of chronic
pain,35-37 seven reviews of neck and back pain,38-44
five reviews of rheumatic diseases,45-49 and four
reviews of headache.50-53 When taken as a whole, the
CRD concluded that acupuncture reduced pain when
compared to no treatment or waiting list controls in
most studies. 33 However, ‘RCTs comparing
acupuncture to a sham technique were more evenly
balanced between those that did and those that did not
show statistically significant differences between
groups.33 [p3] This finding was consistent with an
editorial in the Lancet a decade earlier: ‘...the better
the study technique, the less likely that acupuncture
surpasses the placebo effect.’54
Expert opinion is also available from authors of
numerous textbooks, chapters and tutorial reviews
on acupuncture. In their book Acupuncture: a
Scientific Appraisal, Ernst and White evaluated
systematic reviews on acupuncture as conclusively
positive for dental pain, low back pain and nausea and
vomiting, and conclusively negative for smoking
cessation and weight loss. 55 Evidence was
inconclusive for experimental pain, neck pain,
headache/migraine, osteoarthritis, inflammatory
rheumatic diseases, stroke, addictions and asthma.
Further critique of textbook authors is of limited
value in this article because a clear picture is
emerging. When compared to other treatments the
number of systematic reviews on acupuncture is not
only staggering, but more importantly their
conclusions are conflicting, confusing and often
confounded by methodological inadequacies in the
primary research. However, some of the uncertainty
about the evidence-base for acupuncture has also
been due to a reliance on a review process which is
itself open to bias.
Critically appraising interpretations of clinical
research on acupuncture
Systematic reviews and meta-analyses use scientific
methods in an attempt to remove human prejudice
from the evaluation process. However, scientific
method is grounded in probability theory so answers
(conclusions) will have a degree of uncertainty.
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Moreover, human judgments are critical in the
systematic review process, although the effect of this
is often be ignored in the quest for single sentence
conclusions, clinical bottom lines or plain language
summaries that say more than ‘the results are
inconclusive’.
Shortcomings of systematic reviews
A critical review of clinical research into acupuncture
by White et al revealed shortcomings of the
systematic review process which may distort review
conclusions.56 Imprecise inclusion criteria used by
reviewers led to comparisons of heterogeneous study
populations within the same review. Imprecise
definitions of acupuncture allowed trials to be
included in reviews which acupuncturists would not
consider true acupuncture. For example, laser
acupuncture, which has been included in systematic
reviews, does not ‘puncture’ the skin in the same
way as a needle and is unlikely to elicit the same
physiological effects. Reviews also included control
groups that were potentially ‘active’ and generated
clinically meaningful outcomes in the patient groups.
All of these shortcomings are likely to bias study
outcome towards a negative outcome (ie no
difference between acupuncture and control). Such
methodological shortcomings need to be screened
using robust inclusion and exclusion criteria, or
accounted for in sub-group analysis, as they
compromise review validity.
Discrepancies in vote counting
Linde and Willich highlighted differences in the
outcomes of eight systematic reviews on the
effectiveness of acupuncture for pain.57 They revealed
variations in the number of RCTs included in reviews
on similar topics because of the use of different
inclusion criteria. They also found that variations in
systematic review methodology caused discrepancies
in trial vote counting between similar reviews on
acupuncture and low back pain. Using votes to
summarise the outcome of a primary trial is common
practice when trial data are heterogeneous and cannot
be pooled for statistical analysis. However, vote
counting requires interpretation of trial data by the
reviewers and is open to abuse, especially when trials
use multiple outcome measures presenting with
different results. Judgements about what constitutes
clinically relevant effects and the criteria used to
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compile votes can differ between review groups and
can alter review outcome. For example, similar
reviews on low back pain used three item scales
(positive, negative and neutral) and two item scales
(positive and negative) leading to discrepancies in
the vote counting process between the reviewers.58;44
Inconsistency in judgements about trial outcome in
reviews that dichotomise complex trial data as
positive or negative have been described for
transcutaneous electrical nerve stimulation (TENS),
and dichotomised interpretations of trial reports tend
to be systematically biased towards the reviewers’
conclusion.59 In their reappraisal of acupuncture
reviews, Linde and Willich concluded that: ‘Readers
should be aware that apparently minor decisions in
the review process can have a major impact [on
review outcome].’57 [abstract p1]
Problems with methodological scoring and trial
validity
Credence is given to trials that score high on
methodological quality determined by scoring
methods such as the Cochrane 60-item scale and the
Jadad 5-item scale. These scales give weight to
randomisation and blinding because failure to do so
can exaggerate treatment effects by up to 40% and
17% respectively.60 However, trials can achieve high
methodological quality scores even if they lack
validity or credibility due to insufficient dosing or
inappropriate treatment technique. This is problematic
where optimal treatment technique is not known or
the intervention is administered as part of a
combination therapy as is often the case with
acupuncture.
Smith et al developed an instrument called the
Oxford Pain Validity Scale (OPVS) to measure trial
validity.44 OPVS is a 5-item instrument using a 16point scale to score blinding, sample size, outcomes,
baseline pain and trial sensitivity, and data analysis.
OPVS was piloted as part of a systematic review of
13 RCTs on acupuncture and back and neck pain
with scores ranging from 4 to 14.44 Original trial
authors concluded that acupuncture was effective in
five RCTs and ineffective in eight. However, Smith
et al claimed that trial authors drew conclusions that
were not consistent with trial data. A re-analysis of
trial data revealed that higher validity scores were
associated with negative findings and Smith et al
concluded that there was no convincing evidence
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for the analgesic efficacy of acupuncture for back
or neck pain. This scenario demonstrates that authors
of primary research may misinterpret trial data and
that systematic reviewers may alter the conclusions
of primary research. Interestingly, the OPVS does
not account for adequacy of the treatment intervention
in terms of frequency, duration, timing and technique.
In other words, a trial could achieve a high OPVS
despite under-dosing treatment during the trial.
The importance of adequacy and appropriateness
of treatment intervention
The importance of ensuring that treatment
interventions are adequate in dosage and technique
was revealed in a meta-analysis on the effectiveness
of TENS for postoperative analgesic consumption
pain. 61 A subgroup analysis demonstrated a
significantly better outcome for TENS when applied
using adequate (optimal) stimulation techniques
when compared to non-adequate stimulation
techniques. Optimal TENS techniques were defined
as an intensity that was strong enough to generate a
strong but comfortable paraesthesia, a pulse
frequency that was below 150 pulses per second and
electrodes applied at the site of the operative scar.
Surprisingly, only 11 of 21 published RCTs met these
criteria and they produced a significantly larger
reduction in analgesic consumption of over 30%
when compared to TENS applied inadequately.
The importance of adequate dosing and
appropriate technique in trials of technique based
interventions like acupuncture cannot be over
emphasised and the problem has been recognised.
Ezzo et al examined the effectiveness of acupuncture
for chronic pain and reported that there were 21
positive outcome studies, three negative and 27
neutral.37 Positive results were associated with lowquality methodology and negative results with a risk
of type II errors (false negatives) due to inadequate
sample size. Interestingly, six or more acupuncture
treatments were associated with positive outcomes
even when methodological quality had been taken
into account. However, attempts to develop a method
for assessing the adequacy of acupuncture techniques
used in controlled clinical trials has met with limited
success. White and Ernst used six acupuncture
experts to rate adequacy of acupuncture treatment
and the level of information provided in 15 controlled
clinical trials in which dry needles were inserted into
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the skin for back pain.62 Inter-rater reliability was
low, with ‘considerable variation’ in scores awarded
by the six acupuncture experts, although good
correlation was seen within four of the experts.
Interestingly, determination of adequacy did not
depend on whether needle sensation was elicited, or
how many needles were used. The authors concluded
that this method of assessing adequacy ‘may not be
reliable in other situations because adequacy scores
were inconsistent, possibly indicating problems with
the scale’.62
The difficulty of assessing the adequacy of
interventions in clinical trials of acupuncture has not
prevented the publication of Standards for Reporting
Interventions in Controlled Trials of Acupuncture
(STRICTA) which were modified from the
consolidated standards for reporting trials
(CONSORT).63 The STRICTA recommendations
describe six items that should be included in trial
reports. These are acupuncture rationale; needling
details; treatment regimen; co-interventions;
practitioner background; and control interventions.
Needling details include statements of points used,
numbers of needles inserted, depths of insertion,
responses elicited, needle stimulation, needle insertion
time and needle type. By providing this level of detail
in trial reports, readers and referees will be able to
comment on the appropriateness of interventions,
even if the optimal procedures for acupuncture are
still disputed. When adequate criteria for acupuncture
become available it will be possible to analyse
published work retrospectively. However, two RCTs
recently published in prestigious journals did not
adhere to STRICTA recommendations and omitted
important detail about the acupuncture
intervention.64;65 Vas et al reported that acupuncture
plus diclofenac was better than sham acupuncture
plus diclofenac for osteoarthritis of the knee in a trial
on 97 outpatients, with nine dropouts.64 Distal and
local points were used with local points given
electroacupuncture (EA), although there was no
justification of this approach. The authors claimed to
have achieved adequate blinding, although this would
have been compromised during EA because of
electrical paraesthesia.66 Details of the electrical
characteristics of EA and whether manual
acupuncture needles were ‘twirled’ was absent
because of editorial pressure to restrict space. The
authors were happy to supply the information in
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subsequent correspondence.67 Journals publishing
trials of acupuncture have a duty to allow full
reporting of trial methodology.
Accounting for the physiological intention of
treatment interventions
Investigators also need to consider and report the
physiological intention of acupuncture and whether
this was achieved. For example, the physiological
intention of TENS is to stimulate the skin in order to
activate selectively, non-noxious afferent fibres (ie Abeta), as this is known to generate segmental antinociception. If this is achieved it is more likely that
a patient will obtain pain relief. When non-noxious
afferent fibres are activated the TENS user will report
experiencing ‘a strong but comfortable electrical
TENS paraesthesia’ and this is the criterion used to
ensure adequate technique. It is often stated that the
physiological intention of acupuncture is to stimulate
small diameter nerve fibres arising from deep and
superficial tissue. It is not known whether criteria
could be established to monitor whether this has
been achieved during treatment. One possibility,
which is a matter of some debate, is whether the
sensation of de qi could be used to monitor adequate
stimulation and possibly used as a sensory predictor
of patient response. The acupuncturist in the trial by
Vas et al determined the patient’s sensation of de qi
as an elicitation of needle sensation to check that the
puncture was performed in the ‘correct site’. 64
Unfortunately, the investigators did not record the
number of patients in active and sham groups who
experienced de qi.
Conclusion
It is still relatively easy for advocates to cite primary
research and reviews that show acupuncture in a
positive light and for sceptics to cite primary research
and reviews that show acupuncture in a negative
light. Therefore, it was hardly surprising that the
BMA’s approval of acupuncture was challenged and
defended with such vigour.68 The conclusions of
systematic reviews and meta-analyses depend on the
quality of the primary research. If you put garbage in
to a systematic review you will get garbage out.
Systematic reviewers need to be attentive to the
adequacy of the acupuncture technique used in
clinical trials and whether sufficient dosage was used.
Recently, the publication of better quality clinical
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trials coupled with greater awareness of
methodological issues affecting systematic reviews
of acupuncture have resulted in shifts in review
conclusions, in favour of acupuncture for chronic
back pain. It is hoped that these improvements in
clinical trial design and review methodology can be
rolled out across other pain conditions. For the
immediate future, however, you can be certain that
the uncertainty about the effectiveness of acupuncture
will remain.
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The clinical effectiveness of acupuncture for
pain relief − you can be certain of uncertainty
Mark I Johnson
Acupunct Med 2006 24: 71-79
doi: 10.1136/aim.24.2.71
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