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

Well-conducted systematic reviews (SRs) should in principle provide the most reliable evidence on the effectiveness of acupuncture. However, limitations on the methodological rigour of SRs may impact the trustworthiness of their conclusions. This cross-sectional study was aimed at evaluating the methodological quality of recent SRs of acupuncture.

The Cochrane Database of Systematic Reviews, MEDLINE, and EMBASE were searched for SRs focusing on manual acupuncture or electro-acupuncture published during January 2018 and March 2020. Eligible SRs needed to contain at least one meta-analysis and be published in the English language. Two independent reviewers extracted the bibliographical characteristics of the included SRs with a pre-designed questionnaire and appraised the methodological quality of the reviews with the validated AMSTAR 2 (A MeaSurement Tool to Assess systematic Reviews 2). The associations between bibliographical characteristics and methodological quality ratings were explored using Kruskal-Wallis rank tests and Spearman’s rank correlation coefficients.

A total of 106 SRs were appraised. The results were as follows:

  • one (0.9%) SR was of high methodological quality,
  • no review (0%) was of moderate quality,
  • six (5.7%) were of low quality,
  • 99 (93.4%) were of critically low quality.

Only ten (9.4%) provided an a priori protocol, only four (3.8%) conducted a comprehensive literature search, only five (4.7%) provided a list of excluded studies, and only six (5.7%) performed a meta-analysis appropriately. Cochrane SRs, updated SRs, and SRs that did not search non-English databases had relatively higher overall quality. The vast majority (87.7%) of the 106 reviews included in this analysis originated from Asia. Conflicts of interest of the review authors were declared in only 2 of the 106 reviews.

The authors concluded that the methodological quality of SRs on acupuncture is unsatisfactory. Future reviewers should improve critical methodological aspects of publishing protocols, performing comprehensive search, providing a list of excluded studies with justifications for exclusion, and conducting appropriate meta-analyses. These recommendations can be implemented via enhancing the technical competency of reviewers in SR methodology through established education approaches as well as quality gatekeeping by journal editors and reviewers. Finally, for evidence users, skills in SR critical appraisal remain to be essential as relevant evidence may not be available in pre-appraised formats.

On this blog, I have often complained about the lack of critical input and the poor quality of systematic reviews of so-called alternative medicine (SCAM), particularly of acupuncture, and especially of Chinese reviews, and even more especially Chinese reviews of (mostly) Chinese studies. This new paper is a valuable confirmation of this fast-growing deficit.

One does not need to be a prophet to predict that this pollution of the literature with complete rubbish will have detrimental effects. Because poor reviews almost always draw an over-optimistic picture of the value of acupuncture, this phenomenon must seriously mislead the public. The end result will be that the public believes acupuncture to be effective.

I cannot help thinking that this is, in fact, the intended aim of the authors of such poor, false-positive reviews. Moreover, a glance at the subject areas of the reviews in the list below gives the impression that China is heavily promoting the idea that acupuncture is a panacea. Yet there is good evidence to show that acupuncture is little more than placebo therapy.

In my last post, I have reported that I am an author of many of the frequently-cited systematic acupuncture reviews. You might thus assume that I am a significant part of this pollution by rubbish reviews. This would, however, be an entirely wrong conclusion. The above analysis covers a period when my unit had already been closed, and I am thus not responsible for a single of the papers included in the above analysis.

List of included systematic reviews

ID Included systematic reviews
1 Acupuncture for primary insomnia: An updated systematic review of randomized controlled trials
2 Efficacy and safety of acupuncture for essential hypertension: A meta-analysis
3 Acupuncture for the treatment of sudden sensorineural hearing loss: A systematic review and meta-analysis: Acupuncture for SSNHL
4 Effectiveness of Acupuncturing at the Sphenopalatine Ganglion Acupoint Alone for Treatment of Allergic Rhinitis: A Systematic Review and Meta-Analysis
5 Acupuncture and clomiphene citrate for anovulatory infertility: a systematic review and meta-analysis
6 Acupuncture for primary trigeminal neuralgia: A systematic review and PRISMA-compliant meta-analysis
7 Acupuncture as an adjunctive treatment for angina due to coronary artery disease: A meta-analysis
8 Conventional treatments plus acupuncture for asthma in adults and adolescent: A systematic review and meta-analysis
9 Optimizing acupuncture treatment for dry eye syndrome: A systematic review
10 Acupuncture using pattern-identification for the treatment of insomnia disorder: a systematic review and meta-analysis of randomized controlled trials
11 Efficacy and Safety of Auricular Acupuncture for Cognitive Impairment and Dementia: A Systematic Review
12 Acupuncture for cognitive impairment in vascular dementia, alzheimer’s disease and mild cognitive impairment: A systematic review and meta-analysis
13 Effectiveness of pharmacopuncture for cervical spondylosis: A systematic review and meta-analysis
14 Acupuncture combined with swallowing training for poststroke dysphagia: a meta-analysis of randomised controlled trials
15 Scalp acupuncture treatment for children’s autism spectrum disorders: A systematic review and meta-analysis
16 Acupuncture for Post-stroke Shoulder-Hand Syndrome: A systematic review and meta-analysis
17 Systematic review of acupuncture for the treatment of alcohol withdrawal syndrome
18 Acupuncture for hip osteoarthritis
19 Clinical Benefits of Acupuncture for the Reduction of Hormone Therapy-Related Side Effects in Breast Cancer Patients: A Systematic Review
20 Combination therapy of scalp electro-acupuncture and medication for the treatment of Parkinson’s disease: A systematic review and meta-analysis
21 Acupuncture for migraine: A systematic review and meta-analysis
22 Acupuncture to Promote Recovery of Disorder of Consciousness after Traumatic Brain Injury: A Systematic Review and Meta-Analysis
23 Acupuncture Compared with Intramuscular Injection of Neostigmine for Postpartum Urinary Retention: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
24 Acupuncture for the relief of hot flashes in breast cancer patients: A systematic review and meta-analysis of randomized controlled trials and observational studies
25 Effectiveness and Safety of Acupuncture for Perimenopausal Depression: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
26 Acupuncture plus Chinese Herbal Medicine for Irritable Bowel Syndrome with Diarrhea: A Systematic Review and Meta-Analysis
27 Electroacupuncture as an adjunctive therapy for motor dysfunction in acute stroke survivors: A systematic review and meta-analyses
28 Acupuncture for Acute Pancreatitis: A Systematic Review and Meta-analysis
29 Acupuncture for chronic fatigue syndrome: a systematic review and meta-analysis
30 Compare the efficacy of acupuncture with drugs in the treatment of Bell’s palsy: A systematic review and meta-analysis of RCTs
31 The effectiveness and safety of acupuncture for the treatment of myasthenia gravis: a systematic review and meta-analysis of randomized controlled trials
32 Acupuncture therapy for fibromyalgia: A systematic review and meta-analysis of randomized controlled trials
33 The effectiveness of acupuncture therapy in patients with post-stroke depression: An updated meta-analysis of randomized controlled trials
34 Fire needling for herpes zoster: A systematic review and meta-analysis of randomized clinical trials
35 Comparison between the Effects of Acupuncture Relative to Other Controls on Irritable Bowel Syndrome: A Meta-Analysis
36 Manual Acupuncture for Optic Atrophy: A Systematic Review and Meta-Analysis
37 Effect of warm needling therapy and acupuncture in the treatment of peripheral facial paralysis: A systematic review and meta-analysis
38 The Effect of Acupuncture in Breast Cancer-Related Lymphoedema (BCRL): A Systematic Review and Meta-Analysis
39 The Efficacy of Acupuncture in Chemotherapy-Induced Peripheral Neuropathy: Systematic Review and Meta-Analysis
40 The maintenance effect of acupuncture on breast cancer-related menopause symptoms: a systematic review
41 The effectiveness of acupuncture in the management of persistent regional myofascial head and neck pain: A systematic review and meta-analysis
42 Acupuncture for the Treatment of Adults with Posttraumatic Stress Disorder: A Systematic Review and Meta-Analysis
43 The effectiveness of superficial versus deep dry needling or acupuncture for reducing pain and disability in individuals with spine-related painful conditions: a systematic review with meta-analysis
44 Effects of dry needling trigger point therapy in the shoulder region on patients with upper extremity pain and dysfunction: a systematic review with meta-analysis
45 Is dry needling effective for low back pain?: A systematic review and PRISMA-compliant meta-analysis
46 The effectiveness and safety of acupuncture for patients with atopic eczema: a systematic review and meta-analysis
47 Comparing verum and sham acupuncture in fibromyalgia syndrome: a systematic review and meta-analysis
48 Acupuncture for symptomatic gastroparesis
49 The Efficacy and Safety of Acupuncture for the Treatment of Children with Autism Spectrum Disorder: A Systematic Review and Meta-Analysis
50 Acupuncture Versus Sham-acupuncture: A Meta-analysis on Evidence for Non-immediate Effects of Acupuncture in Musculoskeletal Disorders
51 Acupuncture Treatment for Post-Stroke Dysphagia: An Update Meta-Analysis of Randomized Controlled Trials
52 Effectiveness of Acupuncture Used for the Management of Postpartum Depression: A Systematic Review and Meta-Analysis
53 Clinical effects and safety of electroacupuncture for the treatment of post-stroke depression: a systematic review and meta-analysis of randomised controlled trials
54 Placebo effect of acupuncture on insomnia: a systematic review and meta-analysis
55 Acupuncture for Chronic Pain-Related Insomnia: A Systematic Review and Meta-Analysis
56 Evidence for Dry Needling in the Management of Myofascial Trigger Points Associated With Low Back Pain: A Systematic Review and Meta-Analysis
57 Warm needle acupuncture in primary osteoporosis management: a systematic review and meta-analysis
58 Acupuncture for overactive bladder in adults: a systematic review and meta-analysis
59 Traditional acupuncture for menopausal hot flashes: A systematic review and meta-analysis of randomized controlled trials
60 The effectiveness of acupuncture for osteoporosis: A systematic review and meta-analysis
61 Long-term effects of acupuncture for chronic prostatitis/chronic pelvic pain syndrome: Systematic review and single-Arm meta-Analyses
62 Does acupuncture the day of embryo transfer affect the clinical pregnancy rate? Systematic review and meta-analysis
63 Acupuncture treatments for infantile colic: a systematic review and individual patient data meta-analysis of blinding test validated randomised controlled trials
64 Acupuncture performed around the time of embryo transfer: a systematic review and meta-analysis
65 Is Acupuncture Effective for Improving Insulin Resistance? A Systematic Review and Meta-analysis
66 Efficacy of acupuncture in the management of post-apoplectic aphasia: A systematic review and meta-analysis of randomized controlled trials
67 Acupuncture for lumbar disc herniation: a systematic review and meta-analysis
68 Traditional Chinese acupuncture and postpartum depression: A systematic review and meta-analysis
69 Acupuncture for Chronic Pain: Update of an Individual Patient Data Meta-Analysis
70 Acupuncture Therapy for Functional Effects and Quality of Life in COPD Patients: A Systematic Review and Meta-Analysis
71 Electroacupuncture for Reflex Sympathetic Dystrophy after Stroke: A Meta-Analysis
72 The Effect of Patient Characteristics on Acupuncture Treatment Outcomes
73 The efficacy and safety of acupuncture in women with primary dysmenorrhea: A systematic review and meta-analysis
74 Role of acupuncture in the treatment of insulin resistance: A systematic review and meta-analysis
75 Appropriateness of sham or placebo acupuncture for randomized controlled trials of acupuncture for nonspecific low back pain: A systematic review and meta-analysis
76 Evidence of efficacy of acupuncture in the management of low back pain: a systematic review and meta-analysis of randomised placebo- or sham-controlled trials
77 The effects of acupuncture on pregnancy outcomes of in vitro fertilization: A systematic review and meta-analysis
78 Acupuncture for migraine without aura: a systematic review and meta-analysis
79 Acupuncture for acute stroke
80 Acupuncture at Tiaokou (ST38) for Shoulder Adhesive Capsulitis: What Strengths Does It Have? A Systematic Review and Meta-Analysis of Randomized Controlled Trials
81 Acupuncture for hypertension
82 The effect of acupuncture on Bell’s palsy: An overall and cumulative meta-analysis of randomized controlled trials
83 Effects of acupuncture on cancer-related fatigue: a meta-analysis
84 Acupuncture for adults with overactive bladder
85 Electroacupuncture for Postoperative Urinary Retention: A Systematic Review and Meta-Analysis
86 Meta-Analysis of Electroacupuncture in Cardiac Anesthesia and Intensive Care
87 Acupuncture therapy improves health-related quality of life in patients with chronic obstructive pulmonary disease: A systematic review and meta-analysis
88 The effect of acupuncture on the quality of life in patients with migraine: A systematic review and meta-analysis
89 Cognitive improvement effects of electro-acupuncture for the treatment of MCI compared with Western medications: A systematic review and Meta-analysis 11 Medical and Health Sciences 1103 Clinical Sciences
90 Oriental herbal medicine and moxibustion for polycystic ovary syndrome: A meta-analysis
91 The Effect of Acupuncture and Moxibustion on Heart Function in Heart Failure Patients: A Systematic Review and Meta-Analysis
92 Acupuncture therapy for the treatment of stable angina pectoris: An updated meta-analysis of randomized controlled trials
93 Traditional manual acupuncture combined with rehabilitation therapy for shoulder hand syndrome after stroke within the Chinese healthcare system: a systematic review and meta-analysis
94 Effects of moxibustion on pain behaviors in patients with rheumatoid arthritis: A meta-analysis
95 Acupuncture Treatment for Chronic Pelvic Pain in Women: A Systematic Review and Meta-Analysis of Randomized Controlled Trials
96 The effectiveness of dry needling for patients with orofacial pain associated with temporomandibular dysfunction: a systematic review and meta-analysis
97 Acupuncture for postherpetic neuralgia systematic review and meta-analysis
98 Acupoint selection for the treatment of dry eye: A systematic review and meta-analysis of randomized controlled trials
99 Warm-needle moxibustion for spasticity after stroke: A systematic review of randomized controlled trials
100 Acupuncture for menstrual migraine: a systematic review
101 The efficacy of acupuncture for stable angina pectoris: A systematic review and meta-analysis
102 Acupuncture and weight loss in Asians: A PRISMA-compliant systematic review and meta-analysis
103 Effects of Acupuncture on Breast Cancer-Related lymphoedema: A Systematic Review and Meta-Analysis
104 Acupuncture for infertile women without undergoing assisted reproductive techniques (ART): A systematic review and meta-analysis
105 Moxibustion for alleviating side effects of chemotherapy or radiotherapy in people with cancer
106 Acupuncture for stable angina pectoris: A systematic review and meta-analysis

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