MD, PhD, FMedSci, FRSB, FRCP, FRCPEd

This week is acupuncture awareness week, and I will use this occasion to continue focusing on this therapy. This first time ever event is supported by the British Acupuncture Council who state that it aims to “help better inform people about the ancient practice of traditional acupuncture. With 2.3 million acupuncture treatments carried out each year, acupuncture is one of the most popular complementary therapies practised in the UK today.

Right, let’s inform people about acupuncture then! Let’s show them that there is often more to acupuncture research than meets the eye.

My team and I have done lots of research into acupuncture and probably published more papers on this than any other subject. We had prominent acupuncturists on board from the UK, Korea, China and Japan, we ran conferences, published books and are proud to have been innovative and productive in our multidisciplinary research. But here I do not intend to dwell on our own achievements, rather I will highlight several important new papers in this area.

Korean authors just published a meta-analysis to assess the effectiveness of acupuncture as  therapy for gouty arthritis. Ten RCTs involving 852 gouty arthritis patients were included. Six studies of 512 patients reported a significant decrease in uric acid in the treatment group compared with a control group, while two studies of 120 patients reported no such effect. The remaining four studies of 380 patients reported a significant decrease in pain in the treatment group.

The authors conclude “that acupuncture is efficacious as complementary therapy for gouty arthritis patients”.

We should be delighted with such a positive and neat result! Why then do I hesitate and have doubts?

I believe that this paper reveals several important issues in relation to systematic reviews of Chinese acupuncture trials and studies of other TCM interventions. In fact, this is my main reason for discussing the new meta-analysis here. The following three points are crucial, in my view:

1) All the primary studies were from China, and 8 of the 10 were only available in Chinese.

2) All of them had major methodological flaws.

3) It has been shown repeatedly that all acupuncture-trials from China are positive.

Given this situation, the conclusions of any review for which there are only Chinese acupuncture studies might as well be written before the actual research has started. If the authors are pro-acupuncture, as the ones of the present article clearly are, they will conclude that “acupuncture is efficacious“. If the research team has some critical thinkers on board, the same evidence will lead to an entirely different conclusion, such as “due to the lack of rigorous trials, the evidence is less than compelling.

Systematic reviews are supposed to be the best type of evidence we currently have; they are supposed to guide therapeutic decisions. I find it unacceptable that one and the same set of data could be systematically analysed to generate such dramatically different outcomes. This is confusing and counter-productive!

So what is there to do? How can we prevent being misled by such articles? I think that medical journals should refuse to publish systematic reviews which so clearly lack sufficient critical input. I also believe that reviewers of predominantly Chinese studies should provide English translations of these texts so that they can be independently assessed by those who are not able to read Chinese – and for the sake of transparency, journal editors should insist on this point.

And what about the value of acupuncture for gouty arthritis? I think I let the readers draw their own conclusion.

17 Responses to Systematic reviews of acupuncture-trials – often more than meets the eye

  • Professor Ernst: what is your view regarding the provision of acupuncture within the NHS.

  • for which condition?
    as long as there is good evidence, i am in favour.

  • How about gynaecological conditions? Say for instance polycystic ovararian disease?

  • i am not aware of compelling evidence in relation to POD, but i am keen to learn more, in case you are.

  • So, as an expert in alternative/complementary heathcare you are not aware of evidence for the efficacy of acupuncture for POD. What about other gynaecological conditions? What I mean is, as far as you are aware does acupuncture alter the natural history of any gynaecological condition. Also, in your opinion, and based upon your review of the evidence you and your team have reviewed, is acupuncture of any use for anything other than pain control?

    • no, no, no!
      why don’t you learn to read properly?
      i said that i am not aware of “COMPELLING EVIDENCE IN RELATION TO POD” – that is quite different from what you just put into my mouth, you know.
      “GYNAECOLOGICAL CONDITIONS”????
      there are quite a lot of those; people have written textbooks of more than 2000 pages on gynaecological conditions. so your question is not easy to answer.
      finally, this is a blog and not an exam of up-to-date acupuncture knowledge. try to do the research yourself, please.

  • Calm down dear! It was just a question.
    My concern is that although current evidence base for acupuncture is poor-at least that is what I gather from your observations-it continues to be used for a very very wide range of disorders by both CAM and ‘Orthodox’ practitioners. Lack of evidence seems one of your basic criticisms of CAM and is no doubt one of the main reasons for labelling most CAM methods as ‘quackery’. So it seems strange to me that orthodox practitioners persist in adopting and prescribing quack remedies and do this under the umbrella of their orthodox status and yet avoid a similar label.
    That was all, no need to get heated. Have a great day.

    • no, a quack is a quack, regardless of his/her professional background. my battle – if it is a battle – is not one of one profession against another; it is a battle of against irresponsible/unethical behaviour wherever it occurs in relation to alt med.

  • Oh, and I should have asked… does ‘no,no,no!’ mean NO, acupuncture is not useful for anything other than pain control?

  • it means that i object to be misquoted by you or anyone else.

  • Not aiming to ‘misquote’, just trying to make sure everyone is on a level playing field. And,I’m totally in favour of eliminating quackery and irresponsible and unethical behaviour in healthcare…wherever it occurs!!

  • …and it occurs quite prominently within orthodoxy.

  • I dont use acupuncture. I dont understand it, and I dont see how it works. I try to manage my patients using straightforward orthopaedic principles and I guess that would make me a heretic amongst some members of my profession.

  • and by ‘acupuncture’ I mean traditional acupuncture, ie meridians etc etc and I dont mean ‘dry needling’. I dont use the latter either, but I believe it is useful for some stubborn traction entheseal probelms like tennis elbow.

  • Having undertaken a recent MusculoSkeletal course under the auspices of the British Institute of Musculoskeletal Medicine, I have booked for a foundation course in Acupuncture through the British Medical Acupuncture Society – something I did not see myself considering at all prior to the MSK teaching.

    Why? Well, I have heard much from local specialists (MSK Medics, Orthopods, GPs with special interests etc) in the benefit of ‘Dry Needling’, particularly for intractable soft tissue pain situations. I’m fairly well read on the evidence (or lack thereof) and interested in exploring this from a personal professional point of view. Whilst I am NHS trained, and work within the NHS, I plan to trial the use of dry-needling in my own time, at my own cost.

    I am completely comfortable with the fact that there are little data supporting acupuncture in many non-MSK conditions, and I will be steering well clear of these areas. What does contribute to my change of stance is modest, short term benefits to my own experience of chronic back pain. Given the relative absence of orthodox approaches, I can see the draw of alternatives.

    Just my tuppence worth…

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