MD, PhD, FMedSci, FRSB, FRCP, FRCPEd.

The aim of this review is to synthesise systematic reviews (SRs) of randomised clinical trials (RCTs) evaluating the efficacy of acupuncture to alleviate chronic pain. A total of 177 reviews of acupuncture from 1989 to 2019 met the eligibility criteria. The majority of SRs found that RCTs of acupuncture had methodological shortcomings, including inadequate statistical power with a high risk of bias. Heterogeneity between RCTs was such that meta-analysis was often inappropriate.

Having (co-) authored 13 of these SRs myself, I am impressed with the amount of work that went into this synthesis. The authors should be congratulated for doing it – and for doing it well! The paper itself differentiates the findings according to various types of pain. Here I reproduce the authors’ conclusion regarding different pain entities:

  • Evidence from SRs suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for chronic pain associated with various medical conditions. There is no specific NICE guidance about the use of acupuncture for chronic pain conditions irrespective of aetiology or pathophysiology, although some guidance exists for specific pain conditions (see respective sections below). Guidance by NICE on chronic pain assessment and management is currently being developed (GIDNG10069) with publication expected in August 2020.
  • Evidence from the SRs suggests that acupuncture prevents episodic or chronic tension‐type headaches and episodic migraine, although long‐term studies and studies comparing acupuncture with other treatment options are still required. The current NICE guidance (clinical guideline CG150) is that a course of up to 10 sessions of acupuncture over 5–8 weeks is recommended for tension‐type headache and migraine.
  • The most recent evidence from a Cochrane review of 16 RCTs suggests that acupuncture is not superior to sham acupuncture for OA of the hip, although in contrast, evidence from nonCochrane reviews suggests that there is moderate‐quality evidence that acupuncture may be effective in the symptomatic relief of pain from OA of the knee. Why there should be a difference in evidence between the knee and the hip is not known. Interestingly, guidance from NICE (CG177) states: “Do not offer acupuncture for the management of osteoarthritis”.
  • Evidence suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for low back pain. In 2009, NICE published guidance for the management of nonspecific low back pain that recommended a course of acupuncture as part of first line treatment. This guidance produced much debate. Subsequently, NICE have updated guidance for the management of low back pain and sciatica in people over 16 (NG59) and currently recommend in Section 1.2.8 “Do not offer acupuncture for managing low back pain with or without sciatica”, even though the evidence had not significantly changed.
  • Evidence from SRs suggests that dry needling acupuncture might be effective in alleviating pain associated with myofascial trigger points, at least in the short‐term, although there are insufficient high‐quality RCTs to judge the efficacy with any degree of certainty. There is no guidance from NICE on the management of myofascial pain syndrome.
  • Evidence from the SRs suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for cancer‐related pain and more high‐quality, appropriately designed and adequately powered studies are needed. The most recent guidance from NICE (CSG4) recognises that patients who are receiving palliative care often seek complementary therapies, but it does not specifically recommend acupuncture. It recognises that “Many studies have a considerable number of methodological limitations, making it difficult to draw definitive conclusions”.
  • Evidence from SRs suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for fibromyalgia pain. There is no NICE guidance on the treatment of fibromyalgia.
  • Evidence from the SRs suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for primary dysmenorrhea or chronic pelvic pain. There is NICE guidance on endometriosis (NG73) [200] but this does not recommend any form of Chinese medicine for this type of pelvic pain, although acupuncture is not specifically mentioned.
  • Evidence from the SRs suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for pain in inflammatory arthritis. There is a NICE guideline (NG100) [201] for the treatment of rheumatoid arthritis but this does not recommend acupuncture.
  • Evidence from the SRs suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for neuropathic pain or neuralgia. There is NICE guidance (CG173) on the management of neuropathic pain, but acupuncture is not included in the list of recommended/not recommended treatments.
  • Evidence from SRs suggests that there are insufficient high‐quality RCTs to judge the efficacy of acupuncture for a variety of other painful conditions, including lateral elbow pain, shoulder pain and labour pain. There is no guidance available from NICE on the treatment of any of these conditions.

So, what should we make of all this?

Maybe I just point out two things:

  1. This is a most valuable addition to the literature about acupuncture. It can serve as a reference for all who are interested in an honest account of the (lack of) value of acupuncture in the management of chronic pain.
  2. If a therapy has been tested in hundreds of (sadly often flawed) trials and the conclusions fail to come out clearly in favour of it, it is most likely not a very effective treatment.

Until we have data to the contrary, acupuncture should not be considered to be an effective therapy for chronic pain management.

30 Responses to Acupuncture for the Relief of Chronic Pain? A new, thorough synthesis fails to produce strong evidence that acupuncture works

  • A lot of work in that, I was hoping for a much more in depth set of conclusions on future randomised trials, however, enriched enrollment with randomised withdrawal (EERW) is fascinating, I am not suitably qualified to comment on whether it is possible to use this as a methodology and I see that it has not thus far been used outside of pharma, however, I cannot see why not?

    What does leap from this comparison is how dangerous poorly constructed trials are; they simply leave the window ajar. I’m afraid though, I take little comfort from the general view that no positive outcome in terms of supporting evidence is an equivalency to a negative outcome. That in many ways runs contrary to my legal background but ultimately, I feel that “no evidence for or against a proposition”, is never the same as “strong evidence against”. It raises the specter of that old Scots verdict “not proven”.

    • I take little comfort from the general view that no positive outcome in terms of supporting evidence is an equivalency to a negative outcome. That in many ways runs contrary to my legal background

      They are not just equivalent, they are the same thing.

      A negative outcome in a clinical trial does not mean that the intervention under investigation has not effect. What it means is that the results of the trial are indistinguishable from chance. This may be because the numbers used were too small, or that the trial was badly designed, or for other reasons.

      “no evidence for or against a proposition”, is never the same as “strong evidence against”

      As a doctor I would regard “strong evidence against” as being a positive outcome (i.e. that an effect has been demonstrated, even if it is not what I expected or hoped for).

      I don’t think a legal background is necessarily of much help when it comes to assessing scientific evidence (though my experience of lawyers is that they do have a certain clarity of thinking). The standards of proof required by a Court of Law are quite different from those required by science. A Court simply has to decide which side is right, and what to do about it (damages or a sentence). Even in a criminal case, provided that at least 10 jurors believe a particular version of events “beyond reasonable doubt” that is enough to secure a conviction. By comparison the physicists at CERN had to be a great deal more certain than this before they were happy to announce the discovery of the Higgs boson, and any engineer building a bridge has to be pretty sure of how the design and the materials are going to behave before he can start.

      Biological systems are more difficult due to individual variation and the huge number of random factors determining how the system behaves. Hence the need for statistical tools to tease out real effects from the noise. Any single trial, even if the results are highly statistically significant, could still be subject to the vagaries of chance, particularly if the wrong statistical tests were used or they were applied incorrectly (not all medical researchers are good mathematicians), so it is essential to have independent confirmation, and to be aware of how a given study fits into the current state of knowledge.

  • Thank you for your comments on our paper. Personally, I think it is possibly worth pursuing the EERW design for complex interventions such as acupuncture and I am considering doing some further work on this.

  • Hi, Do you read this article: https://www.ncbi.nlm.nih.gov/pubmed/31855257, I am surprised but many articles are in chinese. Thank’s for your advice Eric

  • I am not a fan of acupuncture and view it as just another treatment availailable for the vulnerable and desperate who are being ‘failed’ by the health system they belong to. However my opinion of NICE is that somewhat inevitably it can only recommend what it can afford. For something to be recommended by NICE it has to be sen to be cost effective for the masses- this seems to fly in the face of individual patient-centred care!

    • @burdle
      Your reasoning is in my opinion seriously flawed. It is practically self-evident that what is effective for the individual is also effective for anyone who needs it and therefore “cost-effective for the masses” as you put it.
      Chronic pain has many, often very complicated causes and is a very commonly ocurring problem. Anything that would genuinely work for such problems, even to a lesser degree, would have swiftly have become mainstream therapy long ago and developed further from there as recognised medical technique. That has not happened with acupuncture. Instead, in the decades since this novel invention appeared on the eastern horizon and became popular in “the west” due to exagerated expectations, most medical practitioners who tried it have either made it a sole source of their livelihood or automatically given up on its use in favour of modern medical methods as they found it significantly inferior or useless.

      • @Bjorn

        “Chronic pain has many, often very complicated causes and is a very commonly ocurring problem. Anything that would genuinely work for such problems, even to a lesser degree, would have swiftly have become mainstream therapy long ago and developed further from there as recognised medical technique.”

        The same can be said for toxic medications … Bjorn. Any reliable drug that is effective, non addictive, and harmless would have taken the world by storm now…. if there were such a thing. The reality is there isn’t, so patients looks for alternatives.

        Again, the failures of SBM.

        • Yes RG, bit the subject here is ACUPUNCTURE, not your perverted disapproval of modern medicine, a subject you do not know anything about.

          • @Bjorn

            So if and when patients experience relief from acupuncture therapy and are pleased with the treatment, why should they be marginalized in relation to patients of SBM that leave with an unmet need, still in want of a solution.

            You live in the double standard.

      • I did not make myself clear. I was not using the masses argument for acupuncture etc.I was just musing on the concept of unique patient centred care n =1 with the fact that RCTs show that some treatments are effective but not for enough to make them economically viable i.e what do we say to tge the one for whon a treatment has appeared to work.

        • Still not grasping things, ”burdle”.
          If something is shown to work in an RCT that is designed, performed and analysed properly, that is evidence of efficacy. If someone thinks he has been helped by something, that is NOT evidence of efficacy. There might be many other reasons for the experience than efficacy of whatever was done or taken.

          If I have a headache and I drink a glass of orange juice and the headache then goes away, that is not evidence that orange juice works for headaches. The most likely explanation for my experience would be that ithe headache would have resolved anyway. If I would infer that it was the orange juice that worked, I would be making a mistake called the “post hoc fallacy”
          A “trial“ with n=1 is not evidence of anything. Now is that so difficult to understand?

          • No It is easy to understand and I still think you are misunderstanding me. I am not making a claim for any SCAM treatment and I am a patient- I am not a scientist. I am passionate about weeding out scam in all its forms and I read what you and Richard and Julian post with great interest to help me formulate my views when I find myself in a position where I personally have to counter scam treatment.

            As I said I was just musing on the ‘patient centered’ care approach and how a patient needs to equip themselves when faced with practitioners who push their treatment in this context etc.

  • This is flogging a dead horse yet again. It has been demonstrated many many times that there is no difference between acupuncture/acupressure and sham acupuncture. That it doesn’t matter if you use needles or toothpicks. It doesn’t even matter if you stick the needles in places that are not acupuncture points or on the supposed meridians. It has even been demonstrated that you can stick needles in a plastic limb rather than the patient’s limb and it works just as well!
    Given all of this it is hard to see how anyone can imagine that acupuncture has any credibility at all.

    In addition there is no scientific basis on which it might work – no-one has ever been able to demonstrate the existence of meridians or the elusive “qi” or how sticking needles in meridians might be able to cure everything from pain to cholecystitis. After all TCM relies on bizarre diagnostic methods such as “kidney” pulse and tongue diagnosis and does not recognize conventional disease classifications such as CHD or germ theory – in other words it exists in an alternative universe.

    SCAM practitioners will never accept that their modalities do not work because it is akin to a religious belief with them – they will keep trying until they get by chance the result they desire however illogical. But first they should ask by what mechanism sticking needles in imaginary meridians might cause relief of myriad symptoms other than as a theatrical placebo working on both the patient and the practitioner?

    At some point they should accept it is time to call it a day!

    • I don’t agree that our work was ‘flogging a dead horse’. It is always useful to collate and synthesise all the current information on acupuncture just because there is so much of it and it needed looking at as a whole to get a flavour of the current state of the evidence. This, to my knowledge, has not been done on this scale before. We hope that it will inform patients, practitioners and providers so that they can make decisions based on the quality of evidence out there. We also made suggestions as to how any future research might be conducted.
      Your paragraph on the scientific basis of acupuncture focuses on Traditional Chinese Medicine theories of acupuncture. We agree that there is no scientific basis for this. However, we approached our review from the standpoint of a Western Medical approach. I think this is an important distinction because there has been some work which demonstrates that acupuncture does have a physiological effect (as of course it must do if you are sticking needles through the skin!). The important question is whether it actually does what protagonists claim it can do.

    • Gosh Burdle I admire your patience and tenacity.

      • I am not sure why? I am completely against SCAM i.e Homeopathy, Reike, Bowen, Acupuncture Cupping . Just in case it is not clear!! I think they all take advantage of the vulnerable and desperate!

  • Thank you for drawing this new review to our attention. It was published just a bit too recently to have been included in our synthesis. However, it has the same issues as many of the other systematic reviews we looked at, not least that ‘Substantial heterogeneity was observed…’ If you look at the author’s list of limitations it mirrors what we concluded in our review. None of the included RCTs had a sufficient sample size to reach any meaningful conclusions. Also, it is interesting that publication bias was not assessed. In our paper we refer to significant issues surrounding publication bias in Chinese acupuncture studies.
    It is useful, however, to add this review to our collection!

  • You can “prove” whatever you’d like. Acupuncture has changed my life. And no it’s not placebo. I’d tried everything else first-and I’ve taken my dog in and placebo isn’t relevant for dogs. Acupuncture is great. You should try it.

    • @Lee Southall. You are not correct that placebo isn’t relevant for dogs. In the case of animals, placebo works on the owner. You are also ignoring other non-specific treatment effects such as regression to the mean. Placebo isn’t the only non-specific treatment effect.

      As to whether the effect you experienced on yourself is down a specific treatment benefit from the acupuncture or non-specific treatment effects it’s not possible for you to know one way or the other. This should not be used as a basis to recommend acupuncture to others.

    • @Lee Southall – I have had patients in the past who have had fantastic results from acupuncture, whatever the mechanism for this is. I personally have given it to myself and it appears to have been effective. However, our paper is a critical synthesis of all the research evidence available and we have found very little good quality evidence that acupuncture is effective. What we do say is that most of the research is of poor quality and have suggested ways that researchers might address these problems. Medicine should, rightly, be evidence-based for the sake of patients, practitioners and providers and therefore it is important that we look objectively at the evidence available rather than relying on anecdotes.

      • experience is the name we give our mistakes

        • @EE

          Professor, by the same token then, experience is the name we give our successes.

          In the case of Lee Southall, and other like myself, why should we rely on studies to tell us what works when we can measure the results for ourselves ?

          The man said it changed it his life, what more proof does he need ? The man is happy with his therapy, and you can not disprove his testimony.

          • for once you made a good point: nobody can disprove a testimony of this nature!
            this is one reason why testimonies are of very little value for showing the effectiveness of a therapy.
            another one is that they never can prove causality.

          • @EE

            Not everybody needs to prove something professor, perhaps the afflicted just wanna feel better, without taking unnecessary risks.

          • experience is the name we give our mistakes

            by the same token then, experience is the name we give our successes.

            Not quite. If something works as expected you generally don’t learn nearly as much from the experience as you do when things go wrong.

          • “If something works as expected you generally don’t learn nearly as much from the experience as you do when things go wrong.”

            Not quite. You might learn different things, though.

        • Prof Ernst – ‘experience is the name we give our mistakes’ .

          Experience tells us many things. It is not, for me anyway, a name I give my mistakes : that would be one-dimensional. However, experience gives us knowledge; a signpost to what is good, bad, safe , unsafe, etc etc ……

          Experience gives me the opportunity to learn by and hopefully rectify my mistakes, and to be open minded and a good listener enabling me to learn :in other words it is a signpost to who I am.

          Experience is different for every human: mine is work in progress. I don’t want to make assumptions for anyone so this is just a little take on my experience of experience.

  • This was an excellent review and the discussion section was particularly well written and informative. Some interesting insights into the shortcomings of existing studies and recommendations for future improvements.

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