Acupuncture for chronic pain: an important up-date

The US ‘Agency for Healthcare Research and Quality (AHRQ) have published a most comprehensive review update entitled ‘Noninvasive Nonpharmacological Treatment for Chronic Pain‘. It followed the AHRQ Methods Guide for Effectiveness and Comparative Effectiveness. The conditions included were:

• Chronic low back pain
• Chronic neck pain
• Osteoarthritis (knee, hip, hand)
• Fibromyalgia
• Chronic tension headache

Here are the main findings related to acupuncture:

LOW BACK PAIN

• Acupuncture was associated with a small improvement in short-term function compared with sham acupuncture or usual care (4 trials); there was no difference between acupuncture and controls in intermediate-term (3 trials) or long-term (1 trial) function (SOE: low). Acupuncture was associated with small improvements in short-term (5 trials) and long-term (1 trial) pain compared with sham acupuncture, usual care, an attention control, or a placebo intervention but there was no difference in intermediate-term pain (5 trials) (SOE: moderate for short term, low for intermediate term and long term).

NECK PAIN

• Acupuncture was associated with small improvements in short-term (5 trials) and intermediate-term (3 trials) function versus sham acupuncture, a placebo (sham laser), or usual care; one trial reported no difference in function in the long term (SOE: low for all time periods). For pain, there were no differences for acupuncture versus sham acupuncture or placebo interventions in the short (4 trials), intermediate (3 trials), or long (1 trial) term (SOE: low for all time periods).

PAIN FROM KNEE OSTEOARTHRITIS

• No differences were seen between acupuncture and control interventions (sham acupuncture, waitlist, or usual care) for function in the short term (4 trials) or the intermediate term (4 trials) (SOE: low for short term; moderate for intermediate term). Stratified analysis showed no differences between acupuncture and sham treatments (4 trials) but moderate improvement in function compared with usual care (2 trials) short term. For pain, there were no differences between acupuncture versus control interventions in the short term (6 trials) or clinically meaningful differences in the intermediate term (4 trials) (SOE: low for short term; moderate for intermediate term). Short-term differences in pain were significant for acupuncture versus usual care but not for acupuncture versus sham acupuncture.

CHRONIC TENSION HEADACHE

• Laser acupuncture was associated with small, short-term improvements in pain intensity and in the number of headache days per month versus sham in one trial (SOE: low).

FIBROMYAGGIA

• Acupuncture was associated with a small improvement in function compared with sham acupuncture at short-term (3 trials [1 new]) and intermediate-term (2 trials) follow-up (SOE: moderate). There was no effect for acupuncture versus sham acupuncture on pain in the short term (4 trials [1 new]) or intermediate term (3 trials) (SOE: low) or based on pooled estimates across control conditions (sham or attention control, 5 trials [2 new]) SOE: low).

HARMS

Treatment-related SAEs were rare (across 5 LBP, 5 neck pain, 4 FM, 1 knee OA, and 1 CTTH trial); only one event (needle insertion site pain lasting1 month) in a LBP patient (<1%) in one trial was considered related to treatment,

SAEs not considered to be related to acupuncture or the study conditions (range 0% to 9% across 5 LBP, 5 neck pain, 4 FM, 1 knee OA, and 1 CTTH trial). These included hospitalization (primarily) or outpatient treatment; reasons were not specified.

The most commonly reported non-serious AEs: swelling, bruising, bleeding or pain at the acupuncture site (1% to 61%, 12 RCTs; or 1% to 18% excluding an outlier trial)); numbness, discomfort, pain or increase in symptoms (1% to 14%; 11 RCTs), dizziness, nausea, fainting (1% to 7%, 7 RCTs), headache (1% to 2%; 4 RCTs), vasovagal symptoms (1% to 4%; 2 RCTs), respiratory problems, chest discomfort (1%; 2 neck pain RCTs), and infection at needle insertion site [1%; 1 RCT (knee OA)]

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I find this interesting, especially if we consider that chronic pain is THE domain for acupuncture (as practised in the West). It shows that, contrary to what so many enthusiasts try to tell us, the evidence for acupuncture is very weak. It also demonstrates that, contrary to what some sceptics assume, the evidence is not totally negative.

As far as harms are concerned, we need to be aware of the fact that the above conclusions are based on clinical trials. We and others have repeatedly shown that in the real of SCAM many, if not most clinical studies fail to mention adverse effects. This means two things: firstly, the trialists violate research ethics; secondly, the above information is woefully incomplete.